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Kohler C, Plaikner A, Siegler K, Hertel H, Hasenbein K, Petzel A, Schubert M, Blohmer JU, Böhmer G, Stolte C, Marnitz S, Mallmann-Gottschalk N, Oppelt P, Favero G, Westphalen S, Hagemann I, Martus P, Schneider A. Radical vaginal trachelectomy: long-term oncologic and fertility outcomes in patients with early cervical cancer. Int J Gynecol Cancer 2024; 34:799-805. [PMID: 38599782 PMCID: PMC11187360 DOI: 10.1136/ijgc-2024-005274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/18/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVE Radical vaginal trachelectomy is a fertility-preserving treatment for patients with early cervical cancer. Despite encouraging oncologic and fertility outcomes, large studies on radical vaginal trachelectomy are lacking. METHOD Demographic, histological, fertility, and follow-up data of consecutive patients who underwent radical vaginal trachelectomy between March 1995 and August 2021 were prospectively recorded and retrospectively analyzed. RESULTS A total of 471 patients of median age 33 years (range 21-44) were included. 83% (n=390) were nulliparous women. Indications were International Federation of Gynecology and Oncology (FIGO, 2009) stages IA1 with lymphvascular space involvement (LVSI) in 43 (9%) patients, IA1 multifocal in 8 (2%), IA2 in 92 (20%), IB1 in 321 (68%), and IB2/IIA in 7 (1%) patients, respectively. LVSI was detected in 31% (n=146). Lymph node staging was performed in 151 patients (32%) by the sentinel node technique with a median of 7 (range 2-14) lymph nodes and in 320 (68%) by systematic lymphadenectomy with a median of 19 (range 10-59) lymph nodes harvested. Residual tumor was histologically confirmed in 29% (n=136). In total, 270 patients (62%) were seeking pregnancy of which 196 (73%) succeeded. There were 205 live births with a median fetal weight of 2345 g (range 680-4010 g). Pre-term delivery occurred in 94 pregnancies (46%). After a median follow-up of 159 months (range 2-312), recurrences were detected in 16 patients (3.4%) of which 43% occurred later than 5 years after radical vaginal trachelectomy. Ten patients (2.1%) died of disease (five more than 5 years after radical vaginal trachelectomy). Overall survival, disease-free survival, and cancer-specific survival were 97.5%, 96.2%, and 97.9%, respectively. CONCLUSION Our study confirms oncologic safety of radical vaginal trachelectomy associated with a high chance for childbearing. High rate of pre-term delivery may be due to cervical volume loss. Our long-term oncologic data can serve as a benchmark for future modifications of fertility-sparing surgery.
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Affiliation(s)
- Christhardt Kohler
- Department of Gynecology, Asklepios Clinic Altona, Hamburg, Germany
- Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree, Berlin, Germny
| | - Andrea Plaikner
- Department of Gynecology, Asklepios Clinic Altona, Hamburg, Germany
| | - Kathrin Siegler
- Department of Gynecology, Asklepios Clinic Altona, Hamburg, Germany
| | - Hermann Hertel
- Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany
| | - Kati Hasenbein
- Specialized Medical Practice for Gynecologic Oncology, Berlin-Spandau, Berlin, Germany
| | - Anja Petzel
- Institute for Dysplasia and Cytology, MVZ Kreuzberg, Berlin, Germany
| | - Melanie Schubert
- Gynecology and Obstetrics, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | | | - Gerd Böhmer
- Institute for Dysplasia and Cytology, IZD Hannover, Hannover, Germany
| | - Claudia Stolte
- Institute for Dysplasia and Cytology, IZD Hannover, Hannover, Germany
| | - Simone Marnitz
- Radiation Oncology Vosspalais, Private Clinic, Berlin, Germany
| | - Nina Mallmann-Gottschalk
- Department of Gynecology and Obstetrics, University Hospital of Cologne Medical Faculty, Cologne, Germany
| | - Peter Oppelt
- Department for Gynecology, Obstetrics and Gynecological Endocrinology, Johannes Kepler University Linz, Linz, Austria
| | - Giovanni Favero
- Department of Gynecology and Obstetrics, Asklepios Hospital Lich, Lich, Germany
| | - Silke Westphalen
- Specialized Medical Practice for Dysplasia and Cytology, Lüneburg, Germany
| | - Ingke Hagemann
- Specialized Medical Practice for Dysplasia and Cytology, Kronshagen, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Biometry, Eberhard Karls University Tübingen Faculty of Medicine, Tubingen, Germany
| | - Achim Schneider
- Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree, Berlin, Germny
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Siegler K, Plaikner A, Hertel H, Hasenbein K, Petzel A, Schubert M, Blohmer JU, Böhmer G, Marnitz S, Ragosch V, Domröse C, Oppelt P, Jülicher A, Schneider A, Willems A, Favero G, Köhler C. Oncologic and Fertility Outcomes After Simple Trachelectomy in Women With Early Cervical Cancer. J Minim Invasive Gynecol 2024; 31:110-114. [PMID: 37951567 DOI: 10.1016/j.jmig.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
STUDY OBJECTIVE This study aimed to present our case series of patients with early-stage cervical cancer undergoing simple trachelectomy (ST). Currently, radical trachelectomy is considered the most appropriate fertility-preserving procedure for the treatment of early-stage cervical cancer. However, there is increasing debate on the appropriate radicality of the surgery to preserve oncologic safety. DESIGN Descriptive retrospective analysis of patient records and evaluation of questionnaires. SETTING 2 gynecologic oncologic centers, surgeries performed by one surgical team. PATIENTS 36 women with early-stage cervical cancer undergoing ST. INTERVENTIONS Laparoscopic assisted simple vaginal trachelectomy. MEASUREMENTS Demographic, histologic, fertility, and follow-up data of all patients who underwent ST between April 2007 and July 2021 were prospectively recorded and retrospectively analyzed. MAIN RESULTS A total of 36 women (mean age: 28 years) underwent ST of whom 81% were nulliparous. Indications for ST were multifocal International Federation of Gynecology and Obstetrics stage IA1 (n = 30), stage IA1 L1 (n = 1), stage IA2 (n = 2), and stage IB1 (n = 3). Mandatory staging procedure was laparoscopic pelvic lymphadenectomy, including bilateral sentinel biopsy in 92% of the cases and systematic in 8%. Residual tumor was histologically confirmed in 8 specimens (22%); 18 women (50%) were seeking parenthood, and 13 succeeded (72%). There were 16 live births, all on term, with a median fetal weight of 3110 grams (2330-4420). One patient had a medical abortion owing to fetal congenital malformation. One pregnancy is ongoing. After a median follow-up of 91.5 months (9-174), all women are alive with no evidence of disease. CONCLUSION ST represents a de-escalation compared with radical trachelectomy and provides excellent oncologic results with an outstanding fertility rate and obstetric outcome for patients with early cervical cancer. However, clear indications for this tailored fertility-preserving surgery have to be defined in well-designed trials.
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Affiliation(s)
- Kathrin Siegler
- Department of Gynecology (Drs. Siegler, Plaikner, and Köhler)
| | - Andrea Plaikner
- Department of Gynecology (Drs. Siegler, Plaikner, and Köhler).
| | - Hermann Hertel
- Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (Dr. Hertel)
| | - Kati Hasenbein
- Specialized Medical Practice for Gynecologic Oncology, Berlin-Spandau, Berlin, Germany (Dr. Hasenbein)
| | - Anja Petzel
- Center for Dysplasia and Cytology, MVZ Kreuzberg, Berlin, Germany (Dr. Petzel)
| | - Melanie Schubert
- Department of Gynecology and Obstetrics, Schleswig-Holstein University Medicine, Campus Kiel, Germany (Dr. Schubert)
| | - Jens Uwe Blohmer
- Department of Gynecology, Charité University Medicine, Campus Mitte, Berlin, Germany (Dr. Blohmer)
| | - Gerd Böhmer
- Center for Dysplasia and Cytology, IZD Hannover, Hannover, Germany (Dr. Böhmer)
| | - Simone Marnitz
- Radiation Oncology Vosspalais, Private Clinic, Berlin, Germany (Dr. Marnitz)
| | - Volker Ragosch
- Department of Obstetrics (Dr. Ragosch), Asklepios Clinic Altona, Hamburg, Germany
| | - Christian Domröse
- Department of Gynecology, University of Cologne, Medical Faculty, Germany (Dr. Domröse)
| | - Peter Oppelt
- Department for Gynecology, Obstetrics and Gynecological Endocrinology, Johannes Kepler University Linz, Austria (Dr. Oppelt)
| | - Anne Jülicher
- Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree Berlin, Germany (Drs. Jülicher, Schneider, and Köhler)
| | - Achim Schneider
- Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree Berlin, Germany (Drs. Jülicher, Schneider, and Köhler)
| | - Anne Willems
- Institute for Dysplasia and Cytology, MVZ Köpenick, Germany (Dr. Willems)
| | - Giovanni Favero
- Department of Gynecology and Obstetrics, Asklepios Hospital Lich, Germany (Dr. Favero)
| | - Christhardt Köhler
- Department of Gynecology (Drs. Siegler, Plaikner, and Köhler); Institute for Dysplasia and Cytology, MVZ Fürstenbergkarree Berlin, Germany (Drs. Jülicher, Schneider, and Köhler); Department of Gynecology, German Red Cross Clinic Berlin Westend, Berlin, Germany (Dr. Köhler)
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3
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Wang Y, Chen Y, Wang M, Qin Z, Zhang L, Zheng A, Han L. Oncological and reproductive outcomes of conization combined with pelvic node evaluation in patients with early-stage cervical cancer: a systematic review and meta-analysis. Front Oncol 2023; 13:1251453. [PMID: 37795440 PMCID: PMC10546176 DOI: 10.3389/fonc.2023.1251453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/30/2023] [Indexed: 10/06/2023] Open
Abstract
Objective This study aims to preliminarily assess the oncological and reproductive outcomes of fertility preservation treatment using conization combined with pelvic node evaluation in young patients with early-stage cervical cancer (ECC) through meta-analysis. Methods In this meta-analysis, we analyzed studies published in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), and Clinical Trials. gov that appeared in our search from inception to 0 7/02/2023. Results There were 17 relevant studies with a total of 620 patients included, of which 444 patients received conization combined with pelvic node evaluation. The combined pregnancy rate was 45.4% (95% CI: 0.34-0.57), the combined live birth rate was 33.9% (95% CI: 0.26-0.42), the combined miscarriage rate was 4.8% (95% CI: 0.02-0.092), the combined preterm delivery rate was 5.1% (95% CI: 0.02-0.092), and the combined recurrence rate was 1.9% (95% CI: 0.006-0.035), which did not significantly differ from that of patients who received radical surgery (OR: 0.689, 95% CI: 0.506-0.938). Conclusion Cervical conization combined with pelvic lymph node evaluation for fertility preservation in young ECC patients can achieve oncological outcomes similar to radical surgery while improving pregnancy success rates and preserving postoperative fertility. In summary, fertility preservation treatment using cervical conization combined with pelvic lymph node evaluation may be considered as a viable option for young ECC patients with strong fertility preservation desire, resulting in better pregnancy and live birth outcomes. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier PROSPERO (CRD42023423432).
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Affiliation(s)
- Yisi Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yali Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Mengyao Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Zhaojuan Qin
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lingli Zhang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Ai Zheng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Ling Han
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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4
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Korompelis P, Rundle S, Cassar V, Ratnavelu N, Ralte A, Biliatis I, Kucukmetin A. Conservative surgical approaches for small volume FIGO stage IB1 cervical cancer. Updated survival and obstetric outcomes of an expanded cohort. Gynecol Oncol 2023; 176:155-161. [PMID: 37542842 DOI: 10.1016/j.ygyno.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Standard surgical treatment of FIGO stage 1B1 cervical cancer is open radical surgery. However, there is increasing evidence that for small tumours a more conservative approach can minimise fertility consequences without impacting on long term oncologic outcomes. The objective of our study is to present survival and obstetric outcomes following extended follow-up for patients who underwent conservative management of small-volume stage 1B1 disease. METHODS All patients with FIGO stage 1B1 cancer and estimated tumour volume of <500 mm3 in a loop biopsy specimen treated in Northern Gynaecological Oncology Centre between December 2000 and December 2021, were included in the study. Clinico-pathological and demographic data were collated alongside detailed follow-up and obstetric outcomes in conjunction with primary care and death register. RESULTS 117 patients underwent conservative surgery for small volume stage 1B1 disease. 58 (49.5%) underwent fertility sparing conservative management with LLETZ while 59 (50.5%) underwent simple hysterectomy. Overall, 95% (111/117) of the patients underwent bilateral pelvic lymphadenectomy and 1 positive node was identified. There was no death related to cervical cancer and 1 recurrence identified during a median follow up of 8.5 years (1-20). 17 pregnancies have been recorded in patients underwent LLETZ and 17 live babies were born. No second trimester miscarriages were noted and there was one preterm delivery (36 weeks). CONCLUSION Non-radical surgery with negative pelvic lymphadenectomy for smallvolume stage 1B1 cervical cancer ensures excellent survival without compromising obstetric outcomes. Should these results be verified by the ongoing prospective studies, radical surgery for these patients may be avoided.
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Affiliation(s)
- Porfyrios Korompelis
- Northern Gynaecological Oncology Centre (NGOC), Queen Elizabeth Hospital, Gateshead, UK.
| | - Stuart Rundle
- Northern Gynaecological Oncology Centre (NGOC), Queen Elizabeth Hospital, Gateshead, UK
| | - Viktor Cassar
- Northern Gynaecological Oncology Centre (NGOC), Queen Elizabeth Hospital, Gateshead, UK
| | - Nithya Ratnavelu
- Northern Gynaecological Oncology Centre (NGOC), Queen Elizabeth Hospital, Gateshead, UK
| | - Angela Ralte
- Pathology Department, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Ali Kucukmetin
- Northern Gynaecological Oncology Centre (NGOC), Queen Elizabeth Hospital, Gateshead, UK
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5
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Wolswinkel JT, Eikelder MLGT, Verhoef CG, Zusterzeel PLM. High- or Intermediate-Risk Histologic Features in Patients with Clinical Early-Stage Cervical Cancer Planned for Fertility-Sparing Surgery: A Systematic Review. Cancers (Basel) 2023; 15:3920. [PMID: 37568735 PMCID: PMC10417237 DOI: 10.3390/cancers15153920] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Fertility-sparing surgery (FSS) is a viable option for young women with early-stage cervical cancer (ECC); however, certain risk factors may necessitate additional treatments and impact fertility. This review examines the prevalence of these risk factors and available treatment options. METHODS A systematic search was conducted of studies including patients with ECC (IA1 with LVSI, IA2, IB1 (FIGO 2009)) who underwent FSS. RESULTS Sixty-four articles, comprising a total of 4118 women planned for FSS, were included. High- or intermediate-risk histologic features were found in 638 (15.5%) women: 5.1% had positive lymph node(s), 4.1% had positive resection margins, 0.3% had parametrial involvement, 1.0% had unspecified high-risk features, and 5.1% had intermediate-risk histology (primarily based on the Sedlis criteria). Adjuvant treatment impaired fertility in all women with adjuvant hysterectomy and/or (chemo)radiation (58.7%). Adjuvant chemotherapy was given to 1351 (32.8%) patients, which may reduce fertility. CONCLUSIONS Fertility preservation could be achieved in most women; but high- or intermediate-risk factors necessitate more extensive surgery or radiotherapy leading to infertility. Adjuvant chemotherapy could be an alternative treatment option considering its effectiveness, safety and higher change in fertility preservation. The low incidence of parametrial involvement justifies waiving parametrectomy in tumors < 2 cm.
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Affiliation(s)
- Janneke T. Wolswinkel
- Department of Obstetrics and Gynecology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; (J.T.W.); (M.L.G.t.E.)
| | - Mieke L. G. ten Eikelder
- Department of Obstetrics and Gynecology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; (J.T.W.); (M.L.G.t.E.)
| | - Cornelia G. Verhoef
- Department of Radiation Oncology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;
| | - Petra L. M. Zusterzeel
- Department of Obstetrics and Gynecology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands; (J.T.W.); (M.L.G.t.E.)
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6
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Furey KB, Anderson ZS, Kuznicki ML, Klar M, Roman LD, Wright JD, Matsuo K. Increasing trends of cervical conization with lymph node evaluation for fertility-sparing surgery in early cervical cancer. Gynecol Oncol 2023; 173:122-129. [PMID: 37137189 DOI: 10.1016/j.ygyno.2023.04.025] [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: 03/15/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To examine uptake, characteristics, and survival outcome of less-radical fertility-sparing surgery with cervical conization and lymph node evaluation (Cone-LN) in reproductive age patients with early cervical cancer. METHODS This retrospective cohort study examined the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population included 407 patients aged <50 years with stage IA-IB2 (≤4 cm) cervical cancer who received fertility-sparing surgery from 2004 to 2019. The exposure was fertility-sparing surgery type: Cone-LN (n = 196) or trachelectomy with lymph node evaluation (Trach-LN, n = 211). The main co-outcomes were (i) temporal trends of surgery type, assessed with Cochran-Armitage test, and (ii) clinical and tumor characteristics, assessed with multivariable binary logistic regression model. The secondary outcome was overall survival, assessed with inverse probability of treatment weighting propensity score. RESULTS The number of patients receiving Cone-LN increased from 43.5% in 2004-2007 to 58.4% in 2016-2019 (P-trend = 0.005). Patients receiving conization and sentinel lymph node (SLN) biopsy alone increased from 0% to 14.4% (P-trend < 0.001). In a multivariable analysis, patients in the Cone-LN group were more likely to undergo SLN biopsy (aOR 6.04) compared to those in the Trach-LN group whereas those with adenocarcinoma (aOR 0.49) and T1b tumors (aOR for ≤2 cm 0.21, and aOR for 2.1-4.0 cm 0.10) were less likely to receive Cone-LN. In a propensity score-weighted model, the Cone-LN and Trach-LN groups had comparable overall survival (7-year rates, 98.9% vs 97.8%). Similar associations were observed for patients with squamous, adenocarcinoma / adenosquamous, T1a classification, and T1b(≤2 cm) classification. CONCLUSION The current population-based analysis suggests that the performance of cervical conization with lymph node evaluation, particularly with SLN biopsy, is gradually increasing for early cervical cancer patients desiring future fertility.
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Affiliation(s)
- Katelyn B Furey
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Zachary S Anderson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Michelle L Kuznicki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
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7
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Morice P, Maulard A, Scherier S, Sanson C, Zarokian J, Zaccarini F, Espenel S, Pautier P, Leary A, Genestie C, Chargari C, Grynberg M, Gouy S. Oncologic results of fertility sparing surgery of cervical cancer: An updated systematic review. Gynecol Oncol 2022; 165:169-183. [PMID: 35241291 DOI: 10.1016/j.ygyno.2022.01.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Several techniques can be proposed as fertility sparing surgery in young patients treated for cervical cancer but uncertaincies remain concerning their outcomes. Analysis of oncological issues is then the first aim of this review in order to evaluate the best strategy. RESULTS Data were identified from searches of MEDLINE, Current Contents, PubMed and from references in relevant articles from January 1987 to 15th of September 2021. We carry out an updated systematic review involving 5862 patients initially selected for fertility-sparing surgery in 275 series. FINDINGS In patients having a stage IB1 disease, recurrence rate/RR in patients undergoing simple conisation/trachelectomy, radical trachelectomy/RT by laparoscopico-vaginal approach, laparotomic or laparoscopic approaches are respectively: 4.1%, 4.7%, 2.4% and 5.2%. In patients having a stage IB2 disease, RR after neoadjuvant chemotherapy or RT by laparotomy are respectively 13.2% and 4.8% (p = .0035). After neoadjuvant treatment a simple cone/trachelectomy was carried out in 91 (30%) patients and a radical one in 210 (70%) cases. But the lowest pregnancy rate is observed in patients undergoing RT by laparotomy (36%). CONCLUSIONS The choice between these treatments should be based above all, on objective oncological data that strike a balance for each procedure between the best chances for cure and the fertility results. In patients having a stage IB1 disease, oncological results are quite similar according to the procedure used. In patients having a stage IB2 disease, RT by open approach has the lowest RR. Anyway the lowest pregnancy rate is observed in patients undergoing RT by laparotomy.
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Affiliation(s)
- P Morice
- Department of Gynecological Surgery, Gustave-Roussy, Villejuif, France; Inserm Unit 10-30, Gustave-Roussy, Villejuif, France; University Paris-Sud (Paris XI), Le Kremlin-Bicêtre, France.
| | - A Maulard
- Department of Gynecological Surgery, Gustave-Roussy, Villejuif, France
| | - S Scherier
- Department of Gynecological Surgery, Gustave-Roussy, Villejuif, France
| | - C Sanson
- Department of Gynecological Surgery, Gustave-Roussy, Villejuif, France
| | - J Zarokian
- Department of Gynecological Surgery, Gustave-Roussy, Villejuif, France
| | - F Zaccarini
- Department of Gynecological Surgery, Gustave-Roussy, Villejuif, France
| | - S Espenel
- Department of Radiation Oncology, Gustave-Roussy, Villejuif, France
| | - P Pautier
- Department of Medical Oncology, Gustave-Roussy, Villejuif, France
| | - A Leary
- Department of Medical Oncology, Gustave-Roussy, Villejuif, France; Inserm Unit 981, Gustave-Roussy, Villejuif, France
| | - C Genestie
- Department of Pathology, Gustave-Roussy, Villejuif, France
| | - C Chargari
- Inserm Unit 10-30, Gustave-Roussy, Villejuif, France; Department of Radiation Oncology, Gustave-Roussy, Villejuif, France
| | - M Grynberg
- University Paris-Sud (Paris XI), Le Kremlin-Bicêtre, France; Department of Reproductive Medicine, Hôpital Antoine-Béclère, Clamart, France
| | - S Gouy
- Department of Gynecological Surgery, Gustave-Roussy, Villejuif, France
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8
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Lucchini SM, Ferreyra HD, Landeros J, Esteban A, Donetch G, Goldsman MG, Borla HF, Heredia F. Conization and lymph node evaluation in low-risk cervical cancer. Is it time to avoid radical surgery? Retrospective series and literature review. Eur J Obstet Gynecol Reprod Biol 2021; 266:163-168. [PMID: 34673464 DOI: 10.1016/j.ejogrb.2021.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/29/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the oncologic and obstetric outcomes of patients with low-risk cervical cancer who underwent conization and lymphatic evaluation to preserve fertility. METHODS Data were collected retrospectively from September 2013 to February 2021. Eligibility criteria included Women with cervical cancer (aged <45 years) who underwent fertility preservation treatment, [stage IA1 with positive lymphovascular space invasion (LVSI), stage IA2, or stage IB1 (≤2 cm) with less <10 mm cervical stromal invasion, according to the International Federaltion of Gynecology and Obstetrics (FIGO) 2018 staging system] aged ≤45 years who wished to preserve their fertility were included in this study. All patients were treated with cervical conization(s) and laparoscopic lymph node evaluation [pelvic lymphadenectomy and/or sentinel lymph node (SLN) mapping]. Oncologic and obstetric outcomes were evaluated. RESULTS Overall, 31 patients met the inclusion criteria; 15 (48.3%) women were nulliparous. There were 8 IA1LVSI+ (25.8%), 11 IA2 (35.4%) and 12 IB1 (31.7%) tumours, according to 2018 FIGO stage classification. Most patients had squamous cell carcinoma (77.4%). Lymphovascular space involvement was found in thirteen patients (41.9%). Reconization was performed in 17 (54.8%) patients, of which 6(35.2%) were done due to compromised margins, 4(23.5%) for margins under than 3 mm, 3(17.6%) for unreported or coagulated margins and 4(23.5%) because previous conization was done in another institution and we could not obtain the paraffin blocks for pathology review. Twenty patients had MRI and eleven CT scan. Nine (30%) patients had a complete bilateral pelvic lymph node dissection, 9 (26.6%) had SLN mapping with pelvic lymphadenectomy, and 13 (43.3%) had SLN mapping alone after bilateral SLN identification at surgery. After a median follow-up of 41.4 months (range 2-90 months), no recurrences have been detected. In terms of obstetrial outcome, 11 patients attempted pregnancy and 9 became pregnant. First-trimester miscarriage occurred in one patient. Five patients delivered at term by caesarean section, one of them requiring hysterectomy at the time of delivery. Pathology did not show residual disease. Two patients had a vaginal delivery at 38 weeks. One pregnancy is still ongoing. CONCLUSION Cervical conization with lymph node assessment by SLN mapping/lymphadenectomy is an oncologic safe procedure in patients with low-risk cervical cancer.
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Affiliation(s)
- Sergio M Lucchini
- Department of Gynaecologic Oncology, Sanatorio Allende, Córdoba, Argentina.
| | - Héctor D Ferreyra
- Department of Gynaecologic Oncology, Sanatorio Allende, Córdoba, Argentina
| | - Juan Landeros
- Minimally Invasive Gynaecology and Robotics Staff, Clínica Andes Salud, Concepcion, Chile
| | - Agustín Esteban
- Department of Gynaecologic Oncology, Sanatorio Allende, Córdoba, Argentina
| | - Gastón Donetch
- Minimally Invasive Gynaecology and Robotics Staff, Clínica Andes Salud, Concepcion, Chile
| | - Marcos G Goldsman
- Department of Gynaecologic Oncology, Sanatorio Allende, Córdoba, Argentina
| | - Hernan F Borla
- Department of Gynaecologic Oncology, Sanatorio Allende, Córdoba, Argentina
| | - Fernando Heredia
- Minimally Invasive Gynaecology and Robotics Staff, Clínica Andes Salud, Concepcion, Chile; Department of Gynaecology and Obstetrics, Faculty of Medicine, University of Concepcion, Concepcion, Chile
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Outcomes of the First Pregnancy After Fertility-Sparing Surgery for Early-Stage Cervical Cancer. Obstet Gynecol 2021; 138:565-573. [PMID: 34623068 DOI: 10.1097/aog.0000000000004532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate outcomes of the first pregnancy after fertility-sparing surgery in patients with early-stage cervical cancer. METHODS We performed a population-based study of women aged 18-45 years with a history of stage I cervical cancer reported to the 2000-2012 California Cancer Registry. Data were linked to the OSHPD (California Office of Statewide Health Planning and Development) birth and discharge data sets. We included patients with cervical cancer who conceived at least 3 months after a fertility-sparing surgery, which included cervical conization or loop electrosurgical excision procedure. Those undergoing trachelectomy were excluded. The primary outcome was preterm birth. Secondary outcomes included growth restriction, neonatal morbidity, stillbirth, cesarean delivery, and severe maternal morbidity. We used propensity scores to match similar women from two groups in a 1:2 ratio of case group participants to control group participants: population individuals without cancer and individuals with cervical cancer (women who delivered before their cervical cancer diagnosis). Wald statistics and logistic regressions were used to evaluate outcomes. RESULTS Of 4,087 patients with cervical cancer, 118 (2.9%) conceived after fertility-sparing surgery, and 107 met inclusion criteria and were matched to control group participants. Squamous cell carcinoma was the most common histology (63.2%), followed by adenocarcinoma (30.8%). Patients in the case group had higher odds of preterm birth before 37 weeks of gestation compared with both control groups (21.5% vs 9.3%, odds ratio [OR] 2.7, 95% CI 1.4-5.1; 21.5% vs 12.7%, OR 1.9, 95% CI 1.0-3.6), but not preterm birth before 32 weeks. Neonatal morbidity was more common among the patients in the case group relative to those in the cervical cancer control group (15.9% vs 6.9%, OR 2.5, 95% CI 1.2-5.5). There were no differences in rates of growth restriction, stillbirth, cesarean delivery, and maternal morbidity. CONCLUSION In a population-based cohort, patients who conceived after surgery for cervical cancer had higher odds of preterm delivery compared with control groups.
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Schmeler KM, Pareja R, Lopez Blanco A, Humberto Fregnani J, Lopes A, Perrotta M, Tsunoda AT, Cantú-de-León DF, Ramondetta LM, Manchana T, Crotzer DR, McNally OM, Riege M, Scambia G, Carvajal JM, Di Guilmi J, Rendon GJ, Ramalingam P, Fellman BM, Coleman RL, Frumovitz M, Ramirez PT. ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer. Int J Gynecol Cancer 2021; 31:1317-1325. [PMID: 34493587 DOI: 10.1136/ijgc-2021-002921] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/11/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The objective of the ConCerv Trial was to prospectively evaluate the feasibility of conservative surgery in women with early-stage, low-risk cervical cancer. METHODS From April 2010 to March 2019, a prospective, single-arm, multicenter study evaluated conservative surgery in participants from 16 sites in nine countries. Eligibility criteria included: (1) FIGO 2009 stage IA2-IB1 cervical carcinoma; (2) squamous cell (any grade) or adenocarcinoma (grade 1 or 2 only) histology; (3) tumor size <2 cm; (4) no lymphovascular space invasion; (5) depth of invasion <10 mm; (6) negative imaging for metastatic disease; and (7) negative conization margins. Cervical conization was performed to determine eligibility, with one repeat cone permitted. Eligible women desiring fertility preservation underwent a second surgery with pelvic lymph node assessment, consisting of sentinel lymph node biopsy and/or full pelvic lymph node dissection. Those not desiring fertility preservation underwent simple hysterectomy with lymph node assessment. Women who had undergone an 'inadvertent' simple hysterectomy with an unexpected post-operative diagnosis of cancer were also eligible if they met the above inclusion criteria and underwent a second surgery with pelvic lymph node dissection only. RESULTS 100 evaluable patients were enrolled. Median age at surgery was 38 years (range 23-67). Stage was IA2 (33%) and IB1 (67%). Surgery included conization followed by lymph node assessment in 44 women, conization followed by simple hysterectomy with lymph node assessment in 40 women, and inadvertent simple hysterectomy followed by lymph node dissection in 16 women. Positive lymph nodes were noted in 5 patients (5%). Residual disease in the post-conization hysterectomy specimen was noted in 1/40 patients-that is, an immediate failure rate of 2.5%. Median follow-up was 36.3 months (range 0.0-68.3). Three patients developed recurrent disease within 2 years of surgery-that is, a cumulative incidence of 3.5% (95% CI 0.9% to 9.0%). DISCUSSION Our prospective data show that select patients with early-stage, low-risk cervical carcinoma may be offered conservative surgery.
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Affiliation(s)
- Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rene Pareja
- Instituto Nacional de Cancerología, Bogotá, and Clínica de Oncología Astorga, Medellin, Colombia
| | | | | | - Andre Lopes
- Instituto Brasileiro de Controle do Cancer, Sao Paulo, Brazil
| | | | | | | | - Lois M Ramondetta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tarinee Manchana
- Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Orla M McNally
- Royal Women's Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Martin Riege
- Instituto de Ginecología de Rosario, Rosario, Argentina
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Catholic University of the Sacred Heart, Rome, Italy
| | | | | | - Gabriel J Rendon
- Instituto de Cancerologia - Las Américas - AUNA, Medellin, Colombia
| | - Preetha Ramalingam
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryan M Fellman
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Michael Frumovitz
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Schwab R, Anic K, Hasenburg A. Cancer and Pregnancy: A Comprehensive Review. Cancers (Basel) 2021; 13:3048. [PMID: 34207252 PMCID: PMC8234287 DOI: 10.3390/cancers13123048] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 01/11/2023] Open
Abstract
Cancer diagnosis and treatment in pregnant women is a challenging situation. A multidisciplinary network of specialists is required to guide both, the expecting mother and the unborn child through the diagnostic workup and the cytotoxic therapy, by balancing the respective risks and benefits. Tumor entity, stage, biology and gestational week at diagnosis determine the appropriate approach. As premature delivery emerged as one of the main risk factors for adverse long-term outcome of the progeny, it should be avoided, if reasonable from the oncological perspective. This article offers a comprehensive review with respect to the various aspects of cancer in pregnancy.
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Affiliation(s)
- Roxana Schwab
- Department of Obstetrics and Women’s Health, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (K.A.); (A.H.)
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