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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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Bréban-Kehl M, Zaccarini F, Sanson C, Maulard A, Scherier S, Genestie C, Chargari C, Pautier P, Leary A, Balleyguier C, Morice P, Gouy S. [Fertility preservation in cervical cancer, analysis of 30 years of practice and immersion in future developments]. ACTA ACUST UNITED AC 2021; 50:62-68. [PMID: 34487915 DOI: 10.1016/j.gofs.2021.09.001] [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: 06/28/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The strategy of fertility preservation (FP) in cervical cancer has been challenged for several years and a therapeutic de-escalation seems to be necessary. In this context, we evaluated the oncological, fertility and obstetric outcomes of surgical techniques performed in our centre for FP. METHODS This retrospective uni centric trial included 75 patients, managed at the Gustave Roussy Institute between 1995 and 2020, for cervical cancer (stage IB1 FIGO 2018) and having conducted a fertility preservation project after a complete pre-therapy work-up. The objective of this study was to understand our results on fertility and obstetrical outcomes and to correlate them with oncological data and finally to evaluate the evolution of our surgical practices. RESULTS 54 patients benefited from an extended trachelectomy and no lymph node involvement was found. 1 patient received a complementary treatment postoperatively which did not allow to preserve her fertility. The recurrence rate was 4.8% (4/75) with one death described. 31 pregnancies were obtained, representing a pregnancy rate of 50%. 74% of pregnancies were obtained spontaneously and 60% of pregnancies were carried to term. CONCLUSION Our results are similar to those in the literature. Despite a fertility preservation project, only half of the patients were able to achieve a pregnancy.
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Affiliation(s)
- M Bréban-Kehl
- Département de chirurgie gynécologique, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - F Zaccarini
- Département de chirurgie gynécologique, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - C Sanson
- Département de chirurgie gynécologique, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - A Maulard
- Département de chirurgie gynécologique, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - S Scherier
- Département de chirurgie gynécologique, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif Cedex, France
| | - C Genestie
- Département d'anatomopathologie, Institut Gustave Roussy, Villejuif, France
| | - Cyrus Chargari
- Département de radiothérapie, Institut Gustave Roussy, Villejuif, France
| | - P Pautier
- Département d'oncologie médicale, Institut Gustave Roussy, Villejuif, France; Unité Inserm U 981 Gustave Roussy, Villejuif, France
| | - A Leary
- Département d'oncologie médicale, Institut Gustave Roussy, Villejuif, France; Unité Inserm U 981 Gustave Roussy, Villejuif, France
| | - C Balleyguier
- Département de radiologie, Institut Gustave Roussy, Villejuif, France
| | - P Morice
- Département de chirurgie gynécologique, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif Cedex, France; Unité Inserm U 10-30, Gustave Roussy, Villejuif, France; Université Paris-Sud (Paris XI), Le Kremlin Bicêtre, France
| | - S Gouy
- Département de chirurgie gynécologique, Institut Gustave Roussy, 114, rue Edouard Vaillant, 94805 Villejuif Cedex, France; Unité Inserm U 10-30, Gustave Roussy, Villejuif, France; Université Paris-Sud (Paris XI), Le Kremlin Bicêtre, France.
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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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Pedra Nobre S, Mazina V, Iasonos A, Zhou QC, Sonoda Y, Gardner G, Long-Roche K, Leitao MM, Abu-Rustum NR, Mueller JJ. Surveillance patterns of cervical cancer patients treated with conization alone. Int J Gynecol Cancer 2020; 30:1129-1135. [PMID: 32499392 PMCID: PMC8336762 DOI: 10.1136/ijgc-2020-001338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES To determine surveillance patterns of stage I cervical cancer after cervical conization. METHODS A 25-question electronic survey was sent to members of the Society of Gynecologic Oncology. Provider demographics, surveillance during year 1, years 1-3, and >3 years after cervical conization, use of pelvic examination, cytology, Human papillomavirus testing, colposcopy, and endocervical curettage were queried. Data were analyzed. RESULTS 239/1175 (20.1%) responses were collected over a 5-week study period. All providers identified as gynecologic oncologists. During year 1, 66.7% of providers perform pelvic examination and 37.1% perform cytology every 3 months. During years 1-3, 61.6% perform pelvic examination and 46% perform cytology every 6 months. At >3 years, 54.4% perform pelvic examination every 6 months and 43% perform annual pelvic examination. 66.7% of respondents perform cytology annually, and 51.9% perform annual Human papilloma virus testing. 85% of providers do not offer routine colposcopy and 60% do not offer endocervical curettage at any point during 5-year follow-up. 76.3% of respondents screen patients for Human papilloma virus vaccination. CONCLUSIONS To date, there are no specific surveillance guidelines for patients with stage I cervical cancer treated with cervical conization. The most common surveillance practice reported is pelvic examination with or without cytology every 3 months in year 1 and every 6 months thereafter. However, wide variation exists in visit frequency, cytology, and Human papillomavirus testing, and there is a clear trend away from using colposcopy and endocervical curettage. These disparate surveillance practices indicate a need for well-defined, uniform surveillance guidelines.
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Affiliation(s)
- Silvana Pedra Nobre
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Varvara Mazina
- Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Alexia Iasonos
- Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Qin C Zhou
- Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Yukio Sonoda
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ginger Gardner
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kara Long-Roche
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mario M Leitao
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nadeem R Abu-Rustum
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jennifer J Mueller
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Kim S, Chung S, Azodi M, Menderes G. Uterine Artery–sparing Minimally Invasive Radical Trachelectomy: A Case Report and Review of the Literature. J Minim Invasive Gynecol 2019; 26:1389-1395. [DOI: 10.1016/j.jmig.2019.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 11/28/2022]
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6
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Reproductive outcomes following treatment for a gynecological cancer diagnosis: a systematic review. J Cancer Surviv 2019; 13:269-281. [DOI: 10.1007/s11764-019-00749-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/22/2019] [Indexed: 01/06/2023]
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7
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Cantillo E, Emerson JB, Mathews C. Less Is More: Minimally Invasive and Quality Surgical Management of Gynecologic Cancer. Obstet Gynecol Clin North Am 2019; 46:55-66. [PMID: 30683266 DOI: 10.1016/j.ogc.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Surgery is a cornerstone of gynecologic oncology. Minimally invasive techniques have been adopted rapidly, in lieu of open approaches, in cervical and endometrial cancer staging. In addition, nodal assessment has undergone significant changes with the introduction of SLN biopsies. The movement toward less is more has also been seen with perioperative and postoperative care and the advent of ERAS protocols, which attempt to maintain normal physiology with the goal of improving functional recovery. It is imperative that new technology be critically evaluated to ensure that oncologic outcomes are not compromised.
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Affiliation(s)
- Evelyn Cantillo
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont College of Medicine, 111 Colchester Avenue, Smith 408, Burlington, VT 05404, USA.
| | - Jenna B Emerson
- Program in Women' Oncology, Women and Infants Hospital, 101 Dudley Street, Providence, RI 02905, USA
| | - Cara Mathews
- Program in Women' Oncology, Women and Infants Hospital, 101 Dudley Street, Providence, RI 02905, USA
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8
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Long-term fertility, oncological, and quality-of-life outcomes after trachelectomy in early stage cervical cancer. Arch Gynecol Obstet 2018; 299:1033-1041. [DOI: 10.1007/s00404-018-4972-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 11/14/2018] [Indexed: 01/27/2023]
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10
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Positive Correlation Between Clearance of High-Risk Human Papillomavirus and Lack of Residual Disease After Loop Excision of the Transformation Zone in Early Stage Cervical Cancer. J Low Genit Tract Dis 2017; 21:294-298. [DOI: 10.1097/lgt.0000000000000327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Fertility Sparing Surgery for Cervical Cancer: Practice Points. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2017. [DOI: 10.1007/s40944-017-0144-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Marth C, Landoni F, Mahner S, McCormack M, Gonzalez-Martin A, Colombo N. Cervical cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28:iv72-iv83. [PMID: 28881916 DOI: 10.1093/annonc/mdx220] [Citation(s) in RCA: 430] [Impact Index Per Article: 61.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- C Marth
- Department of Obstetrics and Gynecology, Medical University Innsbruck, Innsbruck, Austria
| | - F Landoni
- Department of Gynecologic Oncology, European Institute of Oncology, Milan, Italy
| | - S Mahner
- Department of Gynecology and Obstetrics, University of Munich, Munich, Germany
| | - M McCormack
- Department of Oncology, University College Hospital, London, UK
| | - A Gonzalez-Martin
- Medical Oncology Department, MD Anderson Cancer Center, Madrid, Spain
| | - N Colombo
- Department of Gynecologic Oncology, European Institute of Oncology, Milan, Italy
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Lim MC, Lee M, Shim SH, Nam EJ, Lee JY, Kim HJ, Lee YY, Lee KB, Park JY, Kim YH, Ki KD, Song YJ, Chung HH, Kim S, Lee JW, Kim JW, Bae DS, Lee JM. Practice guidelines for management of cervical cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement. J Gynecol Oncol 2017; 28:e22. [PMID: 28382794 PMCID: PMC5391389 DOI: 10.3802/jgo.2017.28.e22] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/23/2017] [Accepted: 03/04/2017] [Indexed: 01/16/2023] Open
Abstract
Clinical practice guidelines for gynecologic cancers have been developed by academic society from several countries. Each guideline reflected their own insurance system and unique medical environment, based on the published evidence. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to develop the third edition of the guidelines in an advanced format based on evidence-based medicine, embracing up-to-date clinical trials and qualified Korean data. These guidelines cover strategies for diagnosis and treatment of primary and recurrent cervical cancer. The committee members and many gynecologic oncologists derived key questions through discussions, and a number of relevant scientific literature were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the management in cervical cancer based on the results in published papers to date and the consensus of experts as a KSGO Consensus Statement.
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Affiliation(s)
- Myong Cheol Lim
- Gynecologic Cancer Branch, Center for Uterine Cancer, and Center for Clinical Trials, Research Institute and Hospital and Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Maria Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hyuk Shim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul, Korea
| | - Eun Ji Nam
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Yun Lee
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Yoo Young Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Beom Lee
- Department of Obstetrics and Gynecology, Gil Medical Center, Gachon University, Incheon, Korea
| | - Jeong Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yun Hwan Kim
- Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung Do Ki
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Yong Jung Song
- Department of Obstetrics and Gynecology, Pusan National University School of Medicine, Pusan, Korea
| | - Hyun Hoon Chung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Sunghoon Kim
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Won Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Duk Soo Bae
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Min Lee
- Department of Obstetrics and Gynecology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea.
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Willows K, Lennox G, Covens A. Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2016; 3:9. [PMID: 27795832 PMCID: PMC5073939 DOI: 10.1186/s40661-016-0030-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/27/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ≥2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease. FINDINGS Available literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors ≥ 2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions ≥ 2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation. CONCLUSION Today, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.
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Affiliation(s)
- Karla Willows
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, M700-610 University Avenue, Toronto, M5G 2 M9 ON Canada
| | - Genevieve Lennox
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, M700-610 University Avenue, Toronto, M5G 2 M9 ON Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Toronto, M700-610 University Avenue, Toronto, M5G 2 M9 ON Canada
- Division of Gynecologic Oncology, T2051 Odette Cancer Centre, University of Toronto, 2075 Bayview Avenue, Toronto, M4N 3 M5 ON Canada
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16
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Fertility-Sparing Options for Early Cervical Cancer: Optimism for Oncologic and Obstetric Outcomes. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0177-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Sato S, Itamochi H, Sugiyama T. Fertility-sparing surgery for uterine cervical cancer. Future Oncol 2016; 12:2345-55. [DOI: 10.2217/fon-2016-0260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The standard treatment for early cervical cancer of the uterus (CC) is radical hysterectomy with resection of the parametrium and pelvic lymphadenectomy. At least 40% of patients develop early-stage CC during child-bearing age, therefore preserving the uterus to maintain fertility has been an important consideration. Several surgical procedures including conization and vaginal or abdominal radical trachelectomy have been reported. These procedures are safe for removing lymph node negative CC tumors with <2 cm diameter. Recently, less radical surgical procedures that maintain fertility, such as conization, simple trachelectomy, minimally invasive surgery and neoadjuvant chemotherapy, have been indicated for tumors greater than 2 cm in diameter. In this review, we discuss the currently accepted surgical approaches for treating CC while maintaining fertility.
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Affiliation(s)
- Seiya Sato
- Department of Obstetrics & Gynecology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka-City 020-8505, Iwate, Japan
| | - Hiroaki Itamochi
- Department of Obstetrics & Gynecology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka-City 020-8505, Iwate, Japan
| | - Toru Sugiyama
- Department of Obstetrics & Gynecology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka-City 020-8505, Iwate, Japan
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Bentivegna E, Maulard A, Pautier P, Chargari C, Gouy S, Morice P. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: a systematic review of the literature. Fertil Steril 2016; 106:1195-1211.e5. [DOI: 10.1016/j.fertnstert.2016.06.032] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/09/2016] [Accepted: 06/20/2016] [Indexed: 01/17/2023]
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Roma AA, Mistretta TA, Diaz De Vivar A, Park KJ, Alvarado-Cabrero I, Rasty G, Chanona-Vilchis JG, Mikami Y, Hong SR, Teramoto N, Ali-Fehmi R, Barbuto D, Rutgers JKL, Silva EG. New pattern-based personalized risk stratification system for endocervical adenocarcinoma with important clinical implications and surgical outcome. Gynecol Oncol 2016; 141:36-42. [PMID: 27016227 DOI: 10.1016/j.ygyno.2016.02.028] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 01/18/2016] [Accepted: 02/21/2016] [Indexed: 11/26/2022]
Abstract
We present a recently introduced three tier pattern-based histopathologic system to stratify endocervical adenocarcinoma (EAC) that better correlates with lymph node (LN) metastases than FIGO staging alone, and has the advantage of safely predicting node-negative disease in a large proportion of EAC patients. The system consists of stratifying EAC into one of three patterns: pattern A tumors characterized by well-demarcated glands frequently forming clusters or groups with relative lobular architecture and lacking destructive stromal invasion or lymphovascular invasion (LVI), pattern B tumors demonstrating localized destructive invasion (small clusters or individual tumor cells within desmoplastic stroma often arising from pattern A glands), and pattern C tumors with diffusely infiltrative glands and associated desmoplastic response. Three hundred and fifty-two cases were included; mean follow-up 52.8 months. Seventy-three patients (21%) had pattern A tumors; all were stage I and there were no LN metastases or recurrences. Pattern B was seen in 90 tumors (26%); all were stage I and LVI was seen in 24 cases (26.6%). Nodal disease was found in only 4 (4.4%) pattern B tumors (one IA2, two IB1, one IB not further specified (NOS)), each of which showed LVI. Pattern C was found in 189 cases (54%), 117 had LVI (61.9%) and 17% were stage II or greater. Forty-five (23.8%) patients showed LN metastases (one IA1, 14 IB1, 5 IB2, 5 IB NOS, 11 II, 5 III and 4 IV) and recurrences were recorded in 41 (21.7%) patients. This new risk stratification system identifies a subset of stage I patients with essentially no risk of nodal disease, suggesting that patients with pattern A tumors can be spared lymphadenectomy. Patients with pattern B tumors rarely present with LN metastases, and sentinel LN examination could potentially identify these patients. Surgical treatment with nodal resection is justified in patients with pattern C tumors.
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Affiliation(s)
| | - Toni-Ann Mistretta
- Baylor College of Medicine, Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Andrea Diaz De Vivar
- Baylor College of Medicine, Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Kay J Park
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Golnar Rasty
- University Health Network, University of Toronto, Toronto, Canada
| | | | | | - Sung R Hong
- Cheil General Hospital & Women's Healthcare Center, Dankook University, Seoul, Republic of Korea
| | | | | | | | | | - Elvio G Silva
- Cedars-Sinai Medical Center, Los Angeles, CA, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Scrivener CG, Gornall R, Rolland P. Simple vaginal trachelectomy as a fertility-sparing treatment to manage high-grade dyskaryosis following multiple large loop excision of the transformation zone. BMJ Case Rep 2016; 2016:bcr2016214627. [PMID: 27353174 PMCID: PMC4932432 DOI: 10.1136/bcr-2016-214627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2016] [Indexed: 11/04/2022] Open
Abstract
A 34-year-old nullipara, wishing to start a family, presented to colposcopy clinic. Her most recent cervical cytology result showed high-grade dyskaryosis. Having undergone four large loop excisions of the transformation zone during the past 6 years, this woman had no remaining vaginal cervix. In order to excise presumed high-grade cervical intraepithelial neoplasia while mitigating obstetric risk, she underwent a simple vaginal trachelectomy and isthmic cerclage. 6 months later, the patient had a negative test of cure. 7 months following surgery she became pregnant naturally. At 29 weeks she had antenatal sepsis of unknown cause, which was treated with intravenous antibiotics. She delivered by caesarean section at 37 weeks and now has a healthy child. This report will discuss the obstetric impact of colposcopic treatment, and simple vaginal trachelectomy as a fertility-sparing treatment option for women who have had multiple loop excision procedures to treat premalignant lesions.
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Affiliation(s)
| | - Robert Gornall
- Department of Gynaecology, Cheltenham General Hospital, Cheltenham, UK
| | - Philip Rolland
- Department of Gynaecology, Cheltenham General Hospital, Cheltenham, UK
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Bentivegna E, Gouy S, Maulard A, Chargari C, Leary A, Morice P. Oncological outcomes after fertility-sparing surgery for cervical cancer: a systematic review. Lancet Oncol 2016; 17:e240-e253. [DOI: 10.1016/s1470-2045(16)30032-8] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 03/17/2016] [Accepted: 03/20/2016] [Indexed: 12/16/2022]
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Salihi R, Leunen K, Van Limbergen E, Moerman P, Neven P, Vergote I. Neoadjuvant chemotherapy followed by large cone resection as fertility-sparing therapy in stage IB cervical cancer. Gynecol Oncol 2015; 139:447-51. [DOI: 10.1016/j.ygyno.2015.05.043] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 05/25/2015] [Accepted: 05/31/2015] [Indexed: 12/15/2022]
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Abstract
In this review, a recently published pattern-based risk stratification system of endocervical adenocarcinoma (EAC) is presented. This novel system evaluates the morphologic features of the tumor and establishes patterns that are associated with a particular tumor behavior. Patients with pattern A EAC do not develop lymph node metastasis, and therefore avoiding lymph node resection in these patients should be considered. These patients also have stage I tumors and conservative surgery would be beneficial to decrease morbidity. Patients with pattern B tumors rarely show metastases to lymph nodes, only if there is lymphovascular invasion, whereas those with pattern C tumors would require aggressive treatment as most lymph node or distant metastases and recurrences were noted in patients with this tumor pattern. Combining this new risk stratification system with an algorithm that surgeons and oncologists could complement to other actionable data would result in a more conservative treatment plan in patients with a new diagnosis of invasive usual-type EAC, as opposed to the current more radical treatment plan. This risk stratification model significantly improves on conventionally used factors such as histologic type, grade, and stage to help manage patients with EAC and identify those in need for aggressive surgical management versus a more conservative approach.
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Bulky Early-Stage Cervical Cancer (2-4 cm Lesions): Upfront Radical Trachelectomy or Neoadjuvant Chemotherapy Followed by Fertility-Preserving Surgery. Int J Gynecol Cancer 2015; 25:722-8. [DOI: 10.1097/igc.0000000000000410] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AbstractRadical trachelectomy is now recognized as a valid treatment option for young women with early-stage cervical cancer with lesions measuring less than 2 cm. However, for women with bulky lesions measuring greater than 2cm, few data are available in the literature to guide management. There are currently 2 options available: either upfront radical trachelectomy or neoadjuvant chemotherapy followed by fertility-preserving surgery. Overall, both options offer very good oncologic outcome; however, the rate of fertility preservation and obstetrical outcome seem superior after neoadjuvant chemotherapy. Advantages and disadvantages of both options are discussed and a thorough literature review is provided. Issues to be further studied are also outlined.
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Halaska M, Robova H, Pluta M, Rob L. The role of trachelectomy in cervical cancer. Ecancermedicalscience 2015; 9:506. [PMID: 25729419 PMCID: PMC4335959 DOI: 10.3332/ecancer.2015.506] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Indexed: 12/30/2022] Open
Abstract
Cervical cancer is one of the most common cancers in women worldwide. Because it often affects women of childbearing age (19–45 years), fertility-sparing surgery is an important issue. The article reviews current viable fertility-sparing options with a special focus on trachelectomy, including vaginal radical trachelectomy, abdominal radical trachelectomy and simple trachelectomy. Neoadjuvant chemotherapy is also discussed. Finally, the decision to proceed with fertility-sparing treatment should be a patient-driven process.
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Affiliation(s)
- Mj Halaska
- Department of Obstetrics and Gynaecology, Second Medical Faculty, Charles University, Prague 150 00, Czech Republic
| | - H Robova
- Department of Obstetrics and Gynaecology, Second Medical Faculty, Charles University, Prague 150 00, Czech Republic
| | - M Pluta
- Department of Obstetrics and Gynaecology, Second Medical Faculty, Charles University, Prague 150 00, Czech Republic
| | - L Rob
- Department of Obstetrics and Gynaecology, Second Medical Faculty, Charles University, Prague 150 00, Czech Republic
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Kadkhodayan S, Hasanzadeh M, Treglia G, Azad A, Yousefi Z, Zarifmahmoudi L, Sadeghi R. Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature. Eur J Surg Oncol 2014; 41:1-20. [PMID: 25454828 DOI: 10.1016/j.ejso.2014.09.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 09/15/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers. METHODS MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity. RESULTS Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits. CONCLUSION Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.
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Affiliation(s)
- S Kadkhodayan
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - M Hasanzadeh
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - G Treglia
- Department of Nuclear Medicine and PET/CT Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - A Azad
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Z Yousefi
- Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - L Zarifmahmoudi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - R Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Noël P, Dubé M, Plante M, St-Laurent G. Early Cervical Carcinoma and Fertility-sparing Treatment Options: MR Imaging as a Tool in Patient Selection and a Follow-up Modality. Radiographics 2014; 34:1099-119. [DOI: 10.1148/rg.344130009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Laparoscopic Radical Trachelectomy Is an Alternative to Laparotomy With Improved Perioperative Outcomes in Patients With Early-Stage Cervical Cancer. Int J Gynecol Cancer 2014; 24:135-40. [DOI: 10.1097/igc.0000000000000031] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveRadical trachelectomy is an established surgical approach for managing young women with cervical cancer wishing to preserve fertility. The aim of this study was to compare perioperative outcomes between laparoscopic (LRT) and abdominal radical trachelectomy (ART).MethodsWe reviewed the records of all women undergoing either LRT or ART in our institution since 2004. Demographic data, clinicopathologic data, and perioperative outcomes were collected and compared between the 2 procedures.ResultsOverall, 27 women were identified. All of them had stage IB1 disease. Eleven (40.8%) women underwent LRT, whereas 16 (59.2%) women underwent ART. Age, parity, and body mass index, as well as histologic type, grade, and presence of lymphovascular space invasion were comparable between groups. The median length of the parametrial tissue removed was shorter in LRT versus ART (P = 0.022). The median blood loss and length of stay were significantly reduced in the LRT group (85 vs 800 mL, P < 0.001; and 4 versus 7 days, P = 0.003). The median operative time was longer with the laparoscopic approach (320 versus 192.5 minutes, P < 0.001). Early grade 1 to 2 postoperative morbidity (mainly high urinary residuals) was comparable between groups; however, more grade 3 and late morbidity events were recorded in the ART group.ConclusionsThis first comparison study between LRT and ART for fertility preservation in women with cervical cancer shows that laparoscopy performed better in terms of blood loss and length of stay. Laparoscopic radical trachelectomy could be the preferred option for these patients; however, further studies are needed to confirm comparable survival outcomes.
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Fertility Conserving Management of Early Cervical Cancer: Our Experience of LLETZ and Pelvic Lymph Node Dissection. Int J Gynecol Cancer 2014; 24:118-23. [DOI: 10.1097/igc.0000000000000023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BackgroundPresently, for those diagnosed with early cervical cancer who wish to conserve their fertility, there is the option of radical trachelectomy. Although successful, this procedure is associated with significant obstetric morbidity. The recurrence risk of early cervical cancer is low and in tumors measuring less than 2 cm; if the lymphatics are negative, the likelihood of parametrial involvement is less than 1%. Therefore, pelvic lymph nodes are a surrogate marker of parametrial involvement and radical excision of the parametrium can be omitted if they are negative.ObjectiveThe aim of this study was to report our experience of the fertility conserving management of early cervical cancer with repeat large loop excision of the transformation zone and laparoscopic pelvic lymph node dissection.MethodsBetween 2004 and 2011, a retrospective review of cases of early cervical cancer who had fertility conserving management within Glasgow Royal Infirmary was done.ResultsForty-three patients underwent fertility conserving management of early cervical cancer. Forty were screen-detected cancers; 2 were stage IA1, 4 were stage IA2, and 37 were stage IB1. There were 2 central recurrences during the follow-up period. There have been 15 live children to 12 women and there are 4 ongoing pregnancies.ConclusionsTo our knowledge, this is the largest case series described and confirms the low morbidity and mortality of this procedure. However, even within our highly select group, there have been 2 cases of central recurrent disease. We, therefore, are urging caution in the global adoption of this technique and would welcome a multicenter multinational randomized controlled trial.
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Ramirez PT, Pareja R, Rendón GJ, Millan C, Frumovitz M, Schmeler KM. Management of low-risk early-stage cervical cancer: should conization, simple trachelectomy, or simple hysterectomy replace radical surgery as the new standard of care? Gynecol Oncol 2013; 132:254-9. [PMID: 24041877 DOI: 10.1016/j.ygyno.2013.09.004] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 09/04/2013] [Accepted: 09/07/2013] [Indexed: 11/25/2022]
Abstract
The standard treatment for women with early-stage cervical cancer (IA2-IB1) remains radical hysterectomy with pelvic lymphadenectomy. In select patients interested in future fertility, the option of radical trachelectomy with pelvic lymphadenectomy is also considered a viable option. The possibility of less radical surgery may be appropriate not only for patients desiring to preserve fertility but also for all patients with low-risk early-stage cervical cancer. Recently, a number of studies have explored less radical surgical options for early-stage cervical cancer, including simple hysterectomy, simple trachelectomy, and cervical conization with or without sentinel lymph node biopsy and pelvic lymph node dissection. Such options may be available for patients with low-risk early-stage cervical cancer. Criteria that define this low-risk group include: squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma, tumor size <2 cm, stromal invasion <10mm, and no lymph-vascular space invasion. In this report, we provide a review of the existing literature on the conservative management of cervical cancer and describe ongoing multi-institutional trials evaluating the role of conservative surgery in selected patients with early-stage cervical cancer.
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Affiliation(s)
- Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Rene Pareja
- Department of Gynecologic Oncology, Instituto de Cancerología Las Américas, Medellín, Colombia
| | - Gabriel J Rendón
- Department of Gynecologic Oncology, Instituto de Cancerología Las Américas, Medellín, Colombia
| | - Carlos Millan
- Department of Gynecology, Hospital Quiron, Murcia, Spain
| | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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