Less radical fertility-sparing surgery than radical trachelectomy in early cervical cancer

Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: Pregnancy outcomes

INTRODUCTION

The standard procedure in cervical cancer is radical hysterectomy and pelvic lymphadenectomy (PLND). Because of the increasing age of women bearing children, fertility has become a major challenge. We present pregnancy results after less radical fertility-sparing surgery in women with IA1, LVSI positive, IA2 and IB1 (<2 cm, infiltration less than half of the cervical stroma).

MATERIALS AND METHOD

All women (n = 91) underwent laparoscopic sentinel lymph node mapping with frozen section followed by PLND and "selective parametrectomy" (removal of afferent lymphatic channels from the paracervix) if sentinel nodes (SLN) are negative. If lymph nodes were verified negative by definitive histopathology, patients were treated by simple trachelectomy (IB1) or large cone (IA1/IA2) biopsy 1 week after primary surgery.

RESULTS

From 1999 to 2018, 91 women were enrolled in the study (median age 29.1 years, range 21-40). Fertility was spared in 76 (83.5%) women; 13 (17.1%) women did not plan future pregnancy and 63 (82.9%) had pregnancy desires. Fifty-four of 63 women conceived (pregnancy rate 85.7%) and 48 of 63 delivered 58 babies (delivery rate 76.2%). Thirty-nine women delivered in term (67.2%): 13 women between 32 and 36 + 6 weeks of pregnancy, 3 between 28 and 31 + 6 weeks and 3 between 24 and 27 + 6 weeks. Only one woman still plans pregnancy. One woman is currently pregnant.

CONCLUSION

The goal of fertility-sparing surgery is to produce good oncological results and promising pregnancy outcomes. Pregnancy results after less radical fertility-sparing procedures show promise (pregnancy rate 82.9% and delivery rate 76.2%).

ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer

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.

Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: Oncological outcomes

INTRODUCTION

The standard procedure in cervical cancer is radical hysterectomy (RH) and pelvic lymphadenectomy (PLND). Because of the increasing age of women at childbirth, fertility becomes a major challenge. We present 20 years of experience with two-step less radical fertility-sparing surgery in women with IA1, LVSI positive, IA2 and IB1 (<2 cm, infiltration less than half of stromal invasions.

MATERIALS AND METHOD

Preoperative workout consisted of histopathological diagnosis and magnetic resonance imaging along with ultrasonographic volumetry. We then performed laparoscopic sentinel lymph node mapping (SLNM) with frozen section (FS) followed by PLND and "selective parametrectomy" (removal of afferent lymphatic channels from the paracervix) in case of a negative result. If verified by definitive histopathology, patients were treated by simple trachelectomy (IB1) or large cone (IA1/IA2) biopsy 1 week after primary surgery.

RESULTS

From 1999 to 2018, 91 women were enrolled in the study (median age 29.1 years, range 21-40). Of these 91 women, 51 (56.0%) were nulliparous. The detection rate of SLNs was 100% per patient and the specific side detection rate 96.7%. Positive lymph nodes were diagnosed in nine cases (9.8%). These women then underwent RH. Fertility was spared in 80 women but 4 recurred locally (5.0%). The mortality rate was 0.0%. The median follow-up was 149 months.

CONCLUSION

Less radical fertility-sparing surgery with SLNM is safe in cervical cancers <2 cm at the largest diameter and infiltrating less than half of the cervical stroma. The recurrence rate is acceptable with no mortality. Morbidity with this procedure is low. Extended and accurate follow-up is necessary and human papillomavirus - high risk (HPV-HR tests seem to be useful in such follow-up assessment.

Fertility-sparing treatment in cervical cancer: Abdominal trachelectomy

In the last two decades, great strides have been made to treat cancer while sparing fertility for young women. This is at least partly in response to changing demographics, including delayed childbearing and fewer historically traditional couples. The trachelectomy has become emblematic in this endeavor. With comparable outcomes to hysterectomy and successful conceptions, trachelectomy utilization has increased over time. It is now a standard of care for many situations. While there are several approaches, (vaginal, laparoscopic, and robotic), the abdominal trachelectomy allows surgeons to overcome several limitations, such as patient anatomy, surgical experience, and resources (i.e. no robot) to provide women everywhere this revolutionary operation. In this chapter, we outline surgical techniques, outcomes, and other aspects of the abdominal trachelectomy.

Pathologic Protocols for Sentinel Lymph Nodes Ultrastaging in Cervical Cancer

CONTEXT.—

Ultrastaging of sentinel lymph nodes (SLNs) is a crucial aspect in the approach to SLN processing. No consensual protocol for pathologic ultrastaging has been approved by international societies to date.

OBJECTIVE.—

To provide a review of the ultrastaging protocol and all its aspects related to the processing of SLNs in patients with cervical cancer.

DATA SOURCES.—

In total, 127 publications reporting data from 9085 cases were identified in the literature. In 24% of studies, the information about SLN processing is entirely missing. No ultrastaging protocol was used in 7% of publications. When described, the differences in all aspects of SLN processing among the studies and institutions are substantial. This includes grossing of the SLN, which is not completely sliced and processed in almost 20% of studies. The reported protocols varied in all aspects of SLN processing, including the thickness of slices (range, 1-5 mm), the number of levels (range, 0-cut out until no tissue left), distance between the levels (range, 40-1000 μm), and number of sections per level (range, 1-5).

CONCLUSIONS.—

We found substantial differences in protocols used for SLN pathologic ultrastaging, which can impact sensitivity for detection of micrometastases and even small macrometastases. Since the involvement of pelvic lymph nodes is the most important negative prognostic factor, such profound discrepancies influence the referral of patients to adjuvant radiotherapy and could potentially cause treatment failure. It is urgent that international societies agree on a consensual protocol before SLN biopsy without pelvic lymphadenectomy is introduced into routine clinical practice.

Abdominal Radical Trachelectomy for Early-Stage Cervical Cancer During Pregnancy: A Provocative Surgical Approach. Overview of the Literature and a Single-Institute Experience

OBJECTIVE

Treatment of pregnancy complication due to malignancy of the cervix constitutes a great clinical challenge between optimal maternal therapy and fetal viability. Radical trachelectomy in early-stage cervical cancer during pregnancy instead of radical hysterectomy presents an alternative approach that can offer a satisfactory outcome for the mother and fetus.

MATERIALS AND METHODS-RESULTS

A literature search of articles in English has been performed. Until now, 28 women with cervical cancer, including 2 who were managed and treated in our institute, who underwent a radical trachelectomy during pregnancy have been reported. We overviewed a total of 13 abdominal trachelectomies, 13 vaginal trachelectomies, and 2 laparoscopic trachelectomies.

CONCLUSIONS

Radical trachelectomy can widen the therapeutic approach of early-stage cervical cancer in pregnant women who wish to preserve their pregnancy, providing a possibility of receiving the proper treatment with no delay.

Can simple trachelectomy or conization show comparable survival rate compared with radical trachelectomy in IA1 cervical cancer patients with lymphovascular space invasion who wish to save fertility? A systematic review and guideline recommendation

OBJECTIVE

This study aims to analyze the published literatures on the effect of less radical fertility-preserving procedures, such as conization or simple trachelectomy, on oncological outcomes in IA1 cervical cancer patients with lymphovascular space invasion (LVSI) through a systematic-review.

METHODS

The EMBASE and MEDLINE databases and Cochrane Library were searched for published studies reporting the oncological outcomes of conization/simple trachelectomy in these patients, through April 2017. The endpoints were recurrence and mortality rates. Data were presented as per the Meta-analysis Of Observational Studies in Epidemiology checklist. Practice guidelines were generated via the Grading of Recommendation, Assessment, Development and Evaluation system.

RESULTS

From 6,755 records, 94 full-texts articles were reviewed for eligibility, and five studies were included in this systematic review. All included studies were nonrandomized studies: two case-control studies comparing conization (n = 14) with hysterectomy (n = 24), and the other three were interrupted time series including conization (n = 20) and simple vaginal trachelectomy (n = 59). During the median follow-up duration of 43 months, no recurrence was reported in both conization and simple trachelectomy groups in IA1 patients with LVSI. From three studies reporting the fertility outcomes, the rates of pregnancy, live birth, preterm delivery, and second-trimester miscarriage were 73% (35/48), 64% (32/50), 10% (5/48), and 6% (3/48), respectively.

CONCLUSION

Results suggest that simple trachelectomy or conization could be performed for IA1 cervical cancer patients with LVSI who want to preserve fertility, although these results are only based on a small number of nonrandomized studies (recommendation grade 2 = weak; evidence level D = very low). Further randomized trials with long-term study period are needed to address this issue.

Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management

Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success

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.

Fertility-sparing surgery for uterine cervical cancer

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.

New pattern-based personalized risk stratification system for endocervical adenocarcinoma with important clinical implications and surgical outcome

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.

Simple vaginal trachelectomy as a fertility-sparing treatment to manage high-grade dyskaryosis following multiple large loop excision of the transformation zone

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.

Long-term outcomes of radical vaginal trachelectomy and laparoscopic pelvic lymphadenectomy after neoadjuvant chemotherapy for the IB1 cervical cancer: A series of 60 cases

OBJECTS

The present study sought to analyze the long-time clinical outcomes of the stage IB1 cervical cancer patients who had received the radical vaginal trachelectomy (RVT) and laparoscopic lymphadenectomy after neoadjuvant chemotherapy (NACT).

METHOD

This is a prospective study of 60 patients potentially selected for RVT for a clinical and radiologic cervical cancer (stages IB 1) less than 2 cm. These patients were treated with surgery combined with preoperative NACT in the Department of Obstetrics and Gynecology, PLA General Hospital. We collected the patients' general clinical information, surgical characteristics and obstetric data, and then assessed their long-term oncological outcomes.

RESULTS

The average operative time of the enrolled cases was 204 min and the average blood loss was 443 mL. The average postoperative hospitalization time was 10.6 days. The postoperative pathologic results indicated that the average parametrical width was 1.99 cm; the average length of removed of cervical was 2.6 cm; the average number of excised pelvic lymph node was 20. The median of the follow-up was 43 months (range between 13month and 12 years). Only one case of recurrence was found. Thus far, totally 42 women had tried to conceive, and 36 of them had live births. The live birth pregnancy rate was 86% (36/42).

CONCLUSION

The radical vaginal trachelectomy in combination with the laparoscopic lymphadenectomy surgical is a safe and effective therapeutic strategy for the for IB 1 cervical cancer.

[Laparoscopic radical trachelectomy for preservation of fertility in early cervical cancer. A case report]

BACKGROUND

Radical hysterectomy is the standard treatment for patients with early-stage cervical cancer. However, for women who wish to preserve fertility, radical trachelectomy is a safe and viable option.

OBJECTIVE

To present the first case of laparoscopic radical trachelectomy performed in the National Cancer Institute, and published in Mexico.

CLINICAL CASE

Patient, 34 years old, gravid 1, caesarean 1, stage IB1 cervical cancer, squamous, wishing to preserve fertility. She underwent a laparoscopic radical trachelectomy and bilateral dissection of the pelvic lymph nodes. Operation time was 330minutes, and the estimated blood loss was 100ml. There were no intraoperative or postoperative complications. The final pathology reported a tumour of 15mm with infiltration of 7mm, surgical margins without injury, and pelvic nodes without tumour. After a 12 month follow-up, the patient is having regular periods, but has not yet tried to get pregnant. No evidence of recurrence.

CONCLUSIONS

Laparoscopic radical trachelectomy and bilateral pelvic lymphadenectomy is a safe alternative in young patients who wish to preserve fertility with early stage cervical cancer.

Review of neoadjuvant chemotherapy and trachelectomy: which cervical cancer patients would be suitable for neoadjuvant chemotherapy followed by fertility-sparing surgery?

The number of patients given neoadjuvant chemotherapy (NAC) followed by fertility-sparing surgery in cervical cancer is still scarce. Only a few centres perform these procedures, and thus, such procedures remain largely in the experimental stage. Patients that do not fulfil the criteria for standard fertility-sparing procedure can be included in studies with NAC followed by fertility-sparing procedure. We must consider that both oncological and pregnancy outcomes are important. Patients with only microscopic disease after NAC are apparently the best candidates for fertility-sparing surgery. Current data are not sufficient to identify the optimal procedure after NAC [abdominal radical trachelectomy (ART) or vaginal radical trachelectomy (VRT) or simple trachelectomy]. Some evidence suggests that pregnancy outcome is better after simple trachelectomy as compared with VRT or ART. Long-term results regarding oncological outcome for this concept are still lacking. Adjuvant chemotherapy in patients with histopathological risk factors (lymphovascular space involvement (LVSI), macroscopic residual disease) would decrease a risk of recurrence.

Radical Vaginal Trachelectomy with Laparoscopic Pelvic Lymphadenectomy for Fertility Preservation in Young Women with Early-Stage Cervical Cancer

The primary objective of this study was to describe our experience with the conservative treatment of early-stage cervical cancer (stages IA1, IA2, and IB1) with radical vaginal trachelectomy (RVT) and laparoscopic pelvic lymphadenectomy. This retrospective observational case series included 36 patients with early cervical cancer. Radical trachelectomy and laparoscopic pelvic lymphadenectomy were performed as described by D. Dargent in 32 of these cases. Oncologic, reproductive, and obstetric outcomes were observed subsequently over a median period of 42 (24-96) weeks. A total of 32 RVTs were preformed with a mean operating time of 117 ± 22.8 (77-167) minutes and an average blood loss of 486 mL (150-800 mL). All obtained resection margins were negative for cancer. Lymphovascular space invasion was noted in 11 (30.55 %) of the cases. No recurrences occurred during the study period. Seven (17.8 %) patients were able to become pregnant postoperatively, five of whom delivered healthy infants near term. Radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy appears to be a safe therapeutic option for fertility preservation in young women with early cervical cancer.

Perioperative Outcomes of Radical Trachelectomy in Early-Stage Cervical Cancer: Vaginal Versus Laparoscopic Approaches

Objective

This study aimed to compare the laparoscopic-assisted radical vaginal trachelectomy (LARVT) and laparoscopic radical trachelectomy (LRT) surgical approaches and provide outcome data on patients who have undergone radical trachelectomy.

Methods

We identified patients who had undergone LARVT or LRT at Samsung Medical Center between January 2005 and March 2013.

Results

A total of 38 patients were identified, and 21 patients had undergone LARVT, whereas 17 patients had undergone LRT. The median age was 32 years for both groups. Most of the patients had a squamous cell carcinoma (68.4%) and International Federation of Gynecology and Obstetrics stage IB1 disease (76.3%). Twenty (52.6%) of 38 patients had tumor size greater than 2 cm. There were no significant differences between groups in the baseline characteristics except for the tumor size. Patients undergoing LRT had significantly larger tumor size than patients undergoing LARVT (median tumor size, 2.7 cm [range, 1.2–3.7] vs 2.1 cm [range, 0.4–3.0],P= 0.032). Perioperative outcomes were similar between groups except for the decline of hemoglobin after surgery. The median decline of hemoglobin indicating blood loss was significantly smaller in the LRT group than in the LARVT group (1.8 g/dL [range, 0.5–3.5] vs 2.6 g/dL [range, 0.7–6.2],P= 0.017). Intraoperative complications occurred in 2 patients (9.5%, 2/21) in LARVT group. Although 52.6% of tumors were larger than 2 cm, recurrence occurred only in 3 (7.9%) patients who underwent LARVT.

Conclusions

The study shows the feasibility of LRT, with the advantage of reduced blood loss. The LRT could be an alternative option for patients with large tumors. Further researches are needed to investigate the long-term outcomes.

The role of trachelectomy in cervical cancer

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.

Fertility preservation by photodynamic therapy combined with conization in young patients with early stage cervical cancer: a pilot study

BACKGROUND

Vaginal radical trachelectomy (VRT) is the standard fertility preserving procedure for early stage cervical cancer patients. There have been reports in the literature, however, that VRT to be too radical procedure for early stage cervical cancer, as its post-operative obstetric morbidity was high. In this study, PDT with Loop electrosurgical excision procedure (LEEP) or conization was investigated as a less radical fertility preserving treatment alternative to VRT for early stage cervical cancer patients.

METHODS

We analyzed data of 21 patients with early stage cervical cancer (stages IA-IIA) who underwent PDT with LEEP/conization from 2003 to 2012. LEEP or conization was performed before PDT in every case. For patients in stage IB1 or above, only those who were confirmed to be free of malignancy in frozen section by pelvic lymph node dissection received PDT. Surface photoillumination with red laser light at a wavelength of 630nm was applied to the cervix and the endocervical canal 48h after intravenous injection of 2mg/kg of photosensitizer.

RESULTS

Median age of the 21 patients was 31 years old (range: 22-43), 19 patients (90.5%) of whom were nulliparous. Majority of the lesions were at stage IA1 (47.6%) or IB1 (42.9%). Histologically, 80.9% were squamous cell carcinoma. 5 patients (23.8%) had a lesion of 2cm or larger in diameter. There was one recurrence (4.7%) and no death during 52.6 months (6-114 months). Of the 13 women who attempted to get pregnant, 10 (76.9%) women conceived a total of 11 pregnancies. The first and second trimester miscarriages were 2 and 1 respectively, and 7 (70%) of the pregnancies reached the third trimester, of which 5 delivered at term. No tumor-related deaths or PDT-related severe adverse effects were noted.

CONCLUSION

PDT combined with LEEP/conization could be an effective fertility sparing conservative treatment for young patients with early stage cervical cancer.

A cut-off value of 2 cm in tumor size is of prognostic value in surgically treated FIGO stage IB cervical cancer

OBJECTIVES

Limited knowledge exists about the value of tumor size in surgically treated cervical cancer (CX) using a tumor size of 2 cm as cut-off value.

METHODS

A total of 366 cases of CX FIGO stage IB who received upfront surgery were evaluated regarding tumor size, the prediction of pelvic lymph node involvement, and recurrence-free and overall survival during a median follow-up time of 94 months. Tumors ≤2.0 cm were defined as small, tumors 2.1-4.0 cm as medium sized and those larger than 4 cm as bulky disease.

RESULTS

Small tumors were seen in 28.7%, medium sized in 52.5% and bulky tumors in 18.9%. There was a significant higher frequency of pelvic lymph node involvement with increasing tumor size (13.3% vs. 23.4% vs. 43.5%, respectively; p<0.001) and an increase of recurrent disease (6.7% vs. 18.8% vs. 29.4%, respectively; p<0.001). The 5-year overall survival rate was significantly reduced with increasing tumor size (94.0% vs. 85.1% vs. 69.9%, respectively; p<0.001). Pelvic lymph node involvement and maximal tumor size were independent prognostic factors for both recurrence-free and overall survival in multivariate analysis.

CONCLUSIONS

The results support that tumor size is of prognostic impact in FIGO stage IB cervical carcinomas. A further substaging is suggested for tumors up to 4.0 cm maximum dimension using a cut-off value of 2.0 cm as discriminator. Patients with tumors ≤2.0 cm may represent low risk disease.

Current status of sentinel lymph node mapping in the management of cervical cancer

The status of regional lymph nodes is the most important prognostic factor in early cervical cancer patients. Pelvic lymph node dissections are routinely performed as a part of standard surgical treatment. Systematic pelvic lymphadenectomy is associated with short- and long-term morbidities. This review discusses single components of the sentinel lymph node mapping (SLNM) technique and results of the detection of sentinel lymph nodes. SLNM biopsy performed by an experienced team for small volume tumors (<2 cm) has high specific side detection rate, excellent negative-predictive value and high sensitivity. Uncommon lymphatic drainage has been reported in 15% of cervical cancer patients. There is sufficient data now to suggest that SLNM with 99mTc plus blue dye in the hands of a surgeon with extensive experience should prove to be an important part of individualized cervical cancer surgery and increase the safety of less radical or fertility-sparing surgery.

Gynecologic malignancy in pregnancy

Gynecologic malignancy during pregnancy is a stressful problem. For the diagnosis and treatment of malignancy during pregnancy, a multidisciplinary approach is needed. Patients should be advised about the benefits and risk of treatment. When selecting a treatment for malignancy during pregnancy, the physiologic changes that occur with the pregnancy should be considered. Various diagnostic procedures that do not harm the fetus can be used. Laparoscopic surgery or laparotomy may be safely performed. The staging approach and treatment should be standard. Systemic chemotherapy during the first trimester should be delayed if possible. Radiation therapy should preferably start postpartum. Although delivery should be delayed preferably until after 35 weeks of gestation, termination of pregnancy may be considered when immediate treatment is required. Subsequent pregnancies do not increase the risk of malignancy recurrence.

Radical vaginal trachelectomy: a fertility-preserving procedure in early cervical cancer in young women

BACKGROUND

Radical vaginal trachelectomy (RVT) is a fertility-preserving operation for young women who have cervical cancer in an early stage and want to have children. The demand for RVT is increasing, because more than 40% of all cases of cervical carcinoma affect women under the age of 44. Women are increasingly having their first child at later ages.

METHODS

We present the results of RVT in more than 300 patients whom we operated on, review pertinent literature retrieved by a selective PubMed search, and evaluate treatment recommendations.

RESULTS

The literature contains data on more than 1000 women treated with RVT and nearly 300 pregnancies after RVT. The 5-year recurrence and mortality rates are 2%-5% and 3%-6%, respectively. RVT is an oncologically safe treatment for women who want to have children. The main criteria for treatment with RVT are that the tumor should be no greater than 2 cm in diameter and that the lymph nodes should be histopathologically free of tumor tissue. The laparoscopic-vaginal technique is the best operative approach to assure a high rate of healing. Only one-third of all patients want to have children a short time after RVT. Their pregnancy rates resemble those of women in the general population. 50% of the children are born prematurely, mainly because of premature rupture of the membranes. Thus, pregnancies after RVT are considered high-risk pregnancies.

CONCLUSION

As many as 48% of women with early-stage cervical carcinoma meet the criteria for RVT. RVT is an oncologically safe method that enables women with early-stage cervical carcinoma to become pregnant and have children. Pregnancy after RVT is associated with an elevated risk of preterm birth and should be managed according to standardized procedures.

Fertility preservation in gynecological cancers

For cancers of reproductive system in women, fertility preservation is complex. Fertility is also affected by therapies, however prevention is possible. Radiotherapy affects gonads, uterus, and subsequent pregnancy outcomes in all ages. However, degree and damage depend on dose, irradiation field, and age at the time of exposure. Ovarian transposition is considered if ovarian involvement is unlikely. Gonadotoxic effects of chemotherapy are related to agent's type, cumulative doses, age, and ovarian reserve. Some agents are highly toxic. Rendering follicular development quiescent by suppression of gonadotropins does reduce the ovarian damage. Simple or radical trachelectomy can be used in early cervical cancer. Fertility saving surgery is possible only in early stage low grade epithelial cancers of the ovary, however, in germ cell tumors even in advanced stages it may be possible to preserve fertility. There are no standard recommendations for endometrial cancer. Embryo, oocyte, and ovarian tissue cryopreservation are possible. The human embryo is very resistant to damage. In view of these possibilities, it is advocated that attention to long term health and quality of life in gonadotoxic therapy must be incorporated into plans as early as possible.

Fertility-preserving surgery in patients with early stage cervical carcinoma

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

Clear Cell Adenocarcinoma of the Female Genital Tract: Long-Term Outcome and Fertility Aspects After Brachytherapy Aimed at a Conservative Treatment

Objectives

To assess the outcome and the fertility aspects in the particular population of cervical and/or vaginal clear cell adenocarcinoma (CCA) associated or not to previous in utero diethylstilbestrol exposure.

Methods

From January 1970 to December 2003, data from 61 consecutive patients with cervical and/or vaginal histologically proven CCA treated with brachytherapy (BT) aimed at a conservative treatment at the Institut Gustave Roussy as a part of treatment were retrospectively analyzed.

Results

The median follow-up was 9.4 years, ranging from 0.3 to 27.4 years. The 5-year specific overall survival rate was 79%. The median time of disease-free survival was 5.8 years. In the subgroup of 42 patients with a cervical CCA, 12 patients tried to be pregnant, 2 patients became pregnant and had miscarriages (P2M2 and P1M1). No pregnancy has been observed in 10 patients exclusively owing to anomalies of the reproductive tract: 6 patients had partial or total diaphragm, 2 patients had an anatomical alteration of the uterus, 1 patient had atrophic endometrium, and 1 patient had primary infertility. In the subgroup of 19 patients with a vaginal CCA, 7 patients tried to be pregnant. All of them had no morphological and/or functional anomalies of the genital tract. Three of 7 patients had delivered healthy babies (P1D1, P2D2, and P3M2D1), and another one had a miscarriage (P1M1). Moreover, all babies were delivered by cesarean section. The pregnancy rate was 10% (6 of 61 patients) with 3 healthy babies.

Conclusion

Conservative approach in patients with female genital tract CCA including BT gives good results with good survival rates and an interesting global pregnancy rate.

Fertility-sparing surgery for early cervical cancer-approach to less radical surgery

OBJECTIVE

To evaluate whether certain patients with early-stage cervical cancer are candidates for less radical surgery when considering fertility-sparing surgery.

DESIGN

Prospective cohort study.

SETTING

Two gynecologic cancer centers (St Thomas' Hospital, London; and West Kent Gynaecological Cancer Centre, Maidstone).

POPULATION

Women with early-stage cervical cancer (n = 66) undergoing fertility-sparing surgery, either simple (SVT) or radical vaginal trachelectomy (RVT).

METHODS

Prospective clinical data collection and review of patient notes, pathology and radiology data, and pregnancy outcomes.

MAIN OUTCOME MEASURES

Postoperative complications, surgical specimen histologic analysis, follow-up data, and obstetric outcome.

RESULTS

A total of 66 women underwent either SVT (n = 15) or RVT (n = 51), with pelvic lymphadenectomy, for stage IA2 or IB1 cervical cancer. There was no residual disease in the SVT specimen in 53% versus 29% after RVT. Clear surgical margins in 100% of SVT specimens with residual disease versus 94% after RVT. Two patients had positive lymph nodes after RVT; one of these declined adjuvant treatment until after egg harvesting and subsequently died of disease (1.5%). Median follow-up was 96 months (range, 12-120 months). One patient had a mid vaginal recurrence (1.5%). Twenty-four women have tried to conceive to date, with 14 women having 17 live births. Live birth pregnancy rate was 70.8%.

CONCLUSIONS

It is possible to select patients for a less radical fertility-sparing procedure through identification of measurable low-risk factors and thus reduce the morbidity caused by conventional RVT. The selection criteria should be stringent and applied within the setting of a cancer center.

Fertility-sparing surgery for early-stage cervical cancer

Nowadays cervical cancer is diagnosed in many women who still want to have children. This led to the need to provide fertility-sparing treatments. The main goal is to maintain reproductive ability without decreasing overall and recurrence-free survival. In this article, we review data on procedures for fertility preservation, namely, vaginal and abdominal trachelectomy, less invasive surgery and neoadjuvant chemotherapy. For each one, oncological and obstetrical outcomes are analyzed. Comparing to traditionally offered radical hysterectomy, the overall oncologic safety is good, with promising obstetrical outcomes.

Fertility-Sparing Management for Bulky Cervical Cancer Using Neoadjuvant Transuterine Arterial Chemotherapy Followed by Vaginal Trachelectomy

Background

Fertility-sparing management for bulky cervical cancer remains under investigation. We investigated the safety of neoadjuvant transuterine arterial chemotherapy (TUAC) followed by a simple vaginal trachelectomy for patients with tumors larger than 3 cm in diameter who desired uterine preservation.

Methods

First, to assess the safety and efficacy of TUAC, survival and pathological complete response data from 39 patients with a diagnosis of stage IB2 to stage IIB cervical cancer who participated in 2 consecutive trials during 1997–2006 were analyzed. The neoadjuvant chemotherapy regimens were a combination of TUAC using cisplatin with intravenous nedaplatin or irinotecan. Second, to assess the safety of fertility-sparing management with TUAC, medical records of patients matching the following criteria were reviewed during the same period: (1) International Federation of Gynecology and Obstetrics stages IB1 to IIA; (2) maximum diameter of tumor, 3 cm or more; (3) squamous cell carcinoma; (4) no radiological findings of lymph node metastasis; and (5) patient’s strong desire for preservation of the uterus and to undergo TUAC.

Results

The overall 5-year survival rate of the 39 enrolled patients was 81.0% (95% confidence interval, 64.8%–93.7%). No malignant cells were found in pathologically examined surgical specimens from 14 patients (35.9%), all of whom were alive without recurrence for more than 7 years after treatment. Based on medical records, 7 patients were eligible according to the fertility-sparing criteria, 1 patient with International Federation of Gynecology and Obstetrics stage IB1 cancer, 5 patients with stage IB2, and 1 patient with stage IIA. One patient with stage IB1 cancer and 2 patients with stage IB2 cancer underwent simple vaginal trachelectomy, resection of paracervical tissues, and abdominal lymphadenectomy. Their disease-free intervals were 86, 120, and 65 months, respectively. All 3 patients had regular menses after surgery but no pregnancies, for personal reasons unrelated to fertility.

Conclusions

Powerful neoadjuvant chemotherapy regimens resulted in a pathological complete response. Long-term disease-free interval was achieved after fertility-sparing management for bulky cervical cancer in 3 cases.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fertility Outcome After Radical Vaginal Trachelectomy: A Prospective Study of 212 Patients

Objective

For treatment in patients with early-stage cervical cancer, radical vaginal trachelectomy (RVT) as a fertility-preserving surgery can be put on a par with radical hysterectomy as to oncologic safety. Our aim was to investigate the fertility concerns and outcome.

Methods

Prospective collection of fertility data of patients treated with RVT. The data were collected on personal communication, by telephone, or e-mail correspondence. Descriptive statistical analysis was performed.

Results

Between March 2005 and April 2010, 212 patients were followed up after RVT. Only 76 patients (35.9%) were seeking parenthood currently. Sixty pregnancies occurred in 50 women. Five patients (8.3%) had first-trimester miscarriage, 3 had second-trimester miscarriage (5.0%), 2 patients decided for pregnancy termination (3.3%), and 1 patient (1.7%) had an ectopic pregnancy. Three women (5.0%) delivered prematurely before 28th weeks of gestation, 15 (25.0%) delivered between 28 and 36 weeks, and 27 women (45.0%) reached full term. Four pregnancies are ongoing.

Conclusions

Preservation of childbearing function is a great advantage for patients with early-stage cervical cancer. Many patients do not seek parenthood immediately. We see no impairment of fertility and have solid data on pregnancy outcome. Premature labor is the main problem in pregnancy after RVT.

[Sentinel lymph node procedure and uterine cancers]

Lymph node metastases in cervical and endometrial cancer are major prognostic factors. Lymph-nodal involvement determines adjuvant therapy. As imagery is not reliable to diagnose lymph node status, pelvic +/- para-aortic lymphadenectomy remains the gold standard. These surgical procedures are, however, responsible for specific morbidity: lymphocele and lymphedema. Sentinel lymph node procedure could avoid lymphadenectomy and their complications in cervical and endometrial cancer with good negative predictive values. We present actual indications, procedure and results of sentinel lymph node procedures in cervical and endometrial cancer.

Conservative management of early stage cervical cancer: is there a role for less radical surgery?

OBJECTIVES

The utility of parametrial resection in women with early stage cervical cancer is controversial. In patients with favorable pathologic characteristics such as tumor size <2cm and the absence of lymphovascular space invasion, the rate of parametrial involvement is very low. More conservative surgical approaches have therefore been suggested. The objective of this report is to review the existing literature in this area and to describe an ongoing prospective study evaluating the safety and efficacy of conservative surgery in women with early stage cervical cancer.

METHODS

We performed a search of PubMed for English language articles published between 1970 and 2010 using the MeSH terms "cervical cancer", "conservative surgery", and "cone biopsy".

RESULTS

Several retrospective studies have shown that <1% of patients with early stage cervical cancer with favorable pathologic characteristics have parametrial involvement. In addition, approximately 60% of patients undergoing radical trachelectomy have no residual disease in the final pathologic specimen. Recent studies have reported on the feasibility and safety of performing less radical surgery consisting of pelvic lymphadenectomy with cone biopsy, simple trachelectomy or simple hysterectomy in women with stage IA1 to IB1 cervical carcinoma. In addition, a prospective, multi-center, international trial is currently being performed to evaluate the outcomes of performing pelvic lymphadenectomy with conservative surgery (simple hysterectomy or cervical conization) in patients with favorable pathologic characteristics. Neoadjuvant chemotherapy followed by conservative surgery is also being explored as an option for patients with larger tumors and other pathologic characteristics that do not meet the criteria to perform conservative surgery alone.

CONCLUSIONS

The rate of parametrial involvement in women with early stage cervical cancer with favorable pathologic characteristics is low. Should the results of ongoing studies be favorable, conservative surgery could become the standard of care for certain women with early stage cervical cancer.