Multicenter research on tumor and pregnancy outcomes in patients with early-stage cervical cancer after fertility-sparing surgery

Surgical, oncologic, and obstetric outcomes of radical trachelectomy in early-stage cervical cancer: results from a retrospective cohort study at Brazil National Cancer Institute

Objective

to analyze oncological, obstetrical, and surgical results of young early-stage cervical cancer patients who underwent radical trachelectomy (RT) surgery and wished to maintain their fertility.

Methodology

a retrospective cohort study was carried out concerning cases attended at the Brazilian National Cancer Institute Gynecology Oncology Service. Patients who underwent RT between January 2005 and January 2021 were included.

Results

A total of 32 patients with median age of 32 years old, 62.5% of whom were nulliparous, were assessed. Concerning cancer type, 65.6% squamous cell carcinoma (SCC) cases, 31.2% adenocarcinoma cases and 3.1% adenosquamous carcinoma cases were verified. Stage IA2 was evidenced in 12.5% of the patients and stage IB < 4 cm in 87.5%. Regarding surgical approaches, 68.25% of the patients underwent vaginal RT (VRT), 18.75%, abdominal RT (ART), 9.3%, the robotic radical trachelectomy (RORT) and 3.1%, video laparoscopy radical trachelectomy (VLRT). The median number of removed lymph nodes was 14, with only two detected as positive. Two cases of positive surgical margins were noted. A total of 3.1% intraoperative and 31.25% postoperative complications were observed, with cervical stenosis being the most common. The recurrence rate of the study was 3.1%, with a median follow-up time of 87 months, where 3.1% deaths occurred. The pregnancy rate of the study was 17.85% (5/28), with 54.5% evolving to live births and 45.5% evolving to abortion.

Conclusion

Radical trachelectomy is a feasible procedure presenting good oncological results and acceptable pregnancy rates.

High- or Intermediate-Risk Histologic Features in Patients with Clinical Early-Stage Cervical Cancer Planned for Fertility-Sparing Surgery: A Systematic Review

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.

Is less more in the surgical treatment of early-stage cervical cancer?

PURPOSE OF REVIEW

This article discusses recent developments towards less radical surgical treatment for early-stage cervical cancer.

RECENT FINDINGS

Surgery is the standard treatment for early-stage cervical cancer. In the last decades, new treatment strategies have been developed aiming to reduce morbidity, without hampering oncological safety. We provide an update of the latest knowledge on safety and morbidity following less radical surgical procedures in early-stage cervical cancer. In cervical cancer with a tumour size of 2 cm or less, radical surgery (simple hysterectomy or fertility-sparing conisation) may be a well tolerated option. For patients with larger lesions (>2 cm) and wishing to preserve fertility, administration of neoadjuvant chemotherapy followed by less extensive surgery appears to be a feasible and well tolerated alternative to abdominal trachelectomy. With regard to lymph node assessment, increasing evidence shows the feasibility of the sentinel lymph node procedure instead of full pelvic lymphadenectomy. Prospective trials reporting on oncological safety are awaited.It is important to exercise caution when new surgical strategies are introduced. Despite promising retrospective data, prospective randomized studies may present unexpected results, for instance, minimally invasive radical hysterectomy showed inferior results compared to laparotomy.

SUMMARY

There is a shift towards less radical treatment for early-stage cervical cancer. This review explores whether and when less is really more.

Fertility preservation techniques in cervical carcinoma

The usefulness of this review is to highlight how a fertility preservation (FP) approach is currently feasible for patients diagnosed with uterine cervical cancer. To this regard, a fertility sparing surgery has just overcome its traditional limits, gained acceptance within the major gynecologic oncology societies thanks to the ability to identify the "ideal" candidates to this conservative treatment. On the other hand, the use of other FPs for oocyte and ovarian cortex cryopreservation is still extremely debated. In fact, the existing risk of tumor spreading during oocyte retrieval necessary for oocyte cryostorage for patients' candidates for neo-adjuvant therapy, as well as the potential hazard of cancer cell dissemination after ovarian tissue replacement in cases of non-squamous type cervical carcinomas should not be underestimated. Therefore, in consideration of the encountered limitations and the need to ensure adequate reproductive health for young uterine cervical cancer survivors, translational research regarding the FP has progressively collected innovative insights into the employment of stemness technology. In this context, the property of ovarian stem cells obtained from the ovarian cortex to generate functional oocytes in women could represent a promising therapeutic alternative to the current procedures for a novel and safer FP approach in cancer survivors.

Oncologic results of fertility sparing surgery of cervical cancer: An updated systematic review

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.

[Fertility preservation in cervical cancer, analysis of 30 years of practice and immersion in future developments]

OBJECTIVES

The strategy of fertility preservation (FP) in cervical cancer has been challenged for several years and a therapeutic de-escalation seems to be necessary. In this context, we evaluated the oncological, fertility and obstetric outcomes of surgical techniques performed in our centre for FP.

METHODS

This retrospective uni centric trial included 75 patients, managed at the Gustave Roussy Institute between 1995 and 2020, for cervical cancer (stage IB1 FIGO 2018) and having conducted a fertility preservation project after a complete pre-therapy work-up. The objective of this study was to understand our results on fertility and obstetrical outcomes and to correlate them with oncological data and finally to evaluate the evolution of our surgical practices.

RESULTS

54 patients benefited from an extended trachelectomy and no lymph node involvement was found. 1 patient received a complementary treatment postoperatively which did not allow to preserve her fertility. The recurrence rate was 4.8% (4/75) with one death described. 31 pregnancies were obtained, representing a pregnancy rate of 50%. 74% of pregnancies were obtained spontaneously and 60% of pregnancies were carried to term.

CONCLUSION

Our results are similar to those in the literature. Despite a fertility preservation project, only half of the patients were able to achieve a pregnancy.

Fertility preserving treatment for gynecologic malignancies: a review of recent literature

PURPOSE OF REVIEW

A significant number of women diagnosed with a gynecologic malignancy meet criteria for fertility-sparing treatment. Women are continuing to delay childbearing; the importance of fertility-sparing therapy is, therefore, increasing. It is imperative that physicians understand the options for, and limitations of, these treatments.

RECENT FINDINGS

Recent research has demonstrated improved outcomes for endometrial cancer by adding targeted hysteroscopic resection to progestin therapy. Cervical cancer research has focused on oncologic and pregnancy outcomes following management with radical trachelectomy, confirming its safety. Given the high rates of preterm birth following trachelectomy, studies have evaluated the adequacy of fertility counseling prior to treatment, and have looked for predictive factors for preterm birth. Additionally, research has shown a rise in the percentage of women receiving conservative treatment for both endometrial and cervical cancer.

SUMMARY

With an increasing number of women seeking conservative treatment, physicians must understand the safety and implications of such therapy. Retrospective studies have demonstrated the safety of fertility-sparing treatment for both endometrial and cervical cancer; prospective research is currently underway to provide better guidance for future directions of fertility-sparing treatment for gynecologic malignancies.

Fertility-Sparing Surgery in Gynecologic Cancer: A Systematic Review

Fertility-sparing surgery (FSS) is increasingly being offered to women with a gynecological malignancy who wish to preserve fertility. In this systematic review, we evaluate the best evidence currently available on oncological and reproductive outcome after FSS for early stage cervical cancer, epithelial ovarian cancer, and endometrial cancer. An extensive literature search was conducted using the electronic databases Medline (OVID), Embase, and Cochrane Library to identify eligible studies published up to December 2020. In total, 153 studies were included with 7544, 3944, and 1229 patients who underwent FSS for cervical, ovarian, and endometrial cancer, respectively. We assessed the different FSS techniques that are available to preserve fertility, i.e., omitting removal of the uterine body and preserving at least one ovary. Overall, recurrence rates after FSS are reassuring and therefore, these conservative procedures seem oncologically safe in the current selection of patients with low-stage and low-grade disease. However, generalized conclusions should be made with caution due to the methodology of available studies, i.e., mostly retrospective cohort studies with a heterogeneous patient population, inducing selection bias. Moreover, about half of patients do not pursue pregnancy despite FSS and the reasons for these decisions have not yet been well studied. International collaboration will facilitate the collection of solid evidence on FSS and the related decision-making process to optimize patient selection and counseling.

Fertility-Sparing Surgery Using Knitted TiNi Mesh Implants and Sentinel Lymph Nodes: A 10-Year Experience

Objectives: The aim of this cohort study is to improve the procedure of fertility-sparing surgery and to assess oncological and reproductive follow-up outcomes after radical trachelectomy (RT) for cervical cancer (T_1a2-1bN_xM₀).Methods: We have suggested the method combining sentinel lymph nodes (SLNs) and cervicoisthmic cerclage using a superelastic knitted TiNi mesh (KTNM) implant to facilitate the primary biomechanical/retention function of the uterus. Sixty-eight consented patients, who underwent fertility-sparing surgery using both transabdominal and laparoscopic route from 2009 through 2019, were recruited in the study and prospectively followed for a mean of 69 months.Results: There were no intraoperative or postoperative complications. No cervical stenoses or mesh failures were noted in all cases. The 5-year overall and recurrence-free survival rates were 100% and 97%, respectively. Two patients indicated recurrence, it occurred in 3 and 36 months. There were 19 (28%) spontaneous pregnancies, 6 resulted in full-term delivery, whereas 2 and 11 ended in miscarriage and early abortion, respectively.Conclusions: This sparing-surgery technique is turned out to be feasible and efficient as allows to achieve well oncologic and fertility outcomes, mimicking the effect of the cervix. It complements existing surgical approaches and may provide further insight into how to overcome challenges even in aggravated cases or previously failed procedures.

Discovery of candidate gene expression signatures in peripheral blood for the screening of cervical cancer

Aim: To investigate whether cervical cancer (CC) and cervical intraepithelial neoplasia (CIN) can be screened by analyzing gene expression profiling of peripheral blood. Methods: RNA-sequencing analysis of blood was performed on 11 CC patients, 21 CIN patients and 19 healthy controls (H). Fifty-nine genes were validated by quantitative real-time PCR using blood samples from 46 H, 83 CC and 32 CIN patients. Results: There were significant differences in the expression levels of six genes between CC and H, five genes between CIN and H and four genes between CC and CIN (p < 0.05). Four genes discriminated cervical lesions from H with a sensitivity of 82.61%, a specificity of 87.83% and an area under the curve of 0.8981. Three genes discriminated CC from CIN with a sensitivity of 53.13%, a specificity of 96.39% and an area under the curve of 0.7786. Conclusion: Our findings provided a promising noninvasive quantitative real-time PCR diagnostic assay of CC and CIN.

Survival After Abdominal Q-M Type B versus C2 Radical Hysterectomy for Early-Stage Cervical Cancer

Purpose

To evaluate the survival outcomes of abdominal Q-M type B and type C2 radical hysterectomy (RH) for early-stage (IA1 (lymphovascular invasion)-IIA2) cervical cancer.

Patients and methods

Based on this multicenter, retrospective cohort study on the clinical diagnosis and treatment for cervical cancer in China (Four C), the survival outcomes of abdominal type B and type C2 RH for early-stage cervical cancer were compared under real-world and matched cohort study conditions.

Results

In total, 46,313 cases were included in the Four C database, among whom 20,018 underwent abdominal type B or type C2 RH. In the real-world study, no differences were found in the 5-year overall survival (OS) between the type B group (n=15,471) and type C2 group (n=4547), but the 5-year disease-free survival (DFS) was lower in the type C2 group (82.1 vs 84.8%, hazard ratio: 1.144). Based on the inclusion criteria, 9135 cases were included and the type C2 group (n=1818) was found to have a lower 5-year OS and DFS (OS: 89.5 vs 92.0%, hazard ratio: 1.393; DFS: 84.3 vs 87.4%, hazard ratio: 1.342). Subsequently, 1799 cases from each group were matched and the type C2 group had a lower 5-year DFS (84.6 vs 88.4%, hazard ratio: 1.332). Upon further analysis of the subgroups, the type C2 group had a lower 5-year OS and DFS (OS: 90.3 vs 93.8%, hazard ratio: 1.522; DFS: 85.2 vs 89.4%, hazard ratio: 1.439).

Conclusion

Q-M type B RH could be used for the treatment of stage IA1 (lymphovascular invasion)-IIA2 cervical cancer.

When risk becomes illness: The personal and social consequences of cervical intraepithelial neoplasia medical surveillance

Background

After the early detection of cervical intraepithelial neoplasia (CIN), medical surveillance of the precancerous lesions is carried out to control risk factors to avoid the development of cervical cancer.

Objective

To explore the effects of medical surveillance on the personal and social lives of women undergoing CIN follow-up and treatment.

Methodology

A generic qualitative study using a poststructuralist perspective of risk management was carried out in a gynecology clinic in a public hospital of the Galician Health Care System (Spain). Participants were selected through purposive sampling. The sample consisted of 21 women with a confirmed diagnosis of CIN. Semistructured interviews were recorded and transcribed, and a thematic analysis was carried out, including researcher triangulation to verify the results of the analysis.

Findings

Two main themes emerged from the participants’ experiences: CIN medical surveillance encounters and risk management strategies are shaped by the biomedical discourse, and the effects of “risk treatment” for patients include (a) profound changes expected of patients, (b) increased patient risk management, and (c) resistance to risk management. While doctors’ surveillance aimed to prevent the development of cervical cancer, women felt they were sick because they had to follow strict recommendations over an unspecified period of time and live with the possibility of a life-threatening disease. Clinical risk management resulted in the medicalization of women’s personal and social lives and produced great uncertainty.

Conclusions

This study is the first to conceptualize CIN medical surveillance as an illness experience for patients. It also problematizes the effects of preventative practices in women’s lives. Patients deal with great uncertainty, as CIN medical surveillance performed by gynecologists simultaneously trivializes the changes expected of patients and underestimates the effects of medical recommendations on patients’ personal wellbeing and social relations.

Use of Vaginal Reconstructive Surgery in Cervical Cancer Patients to Prevent Vaginal Stump Contracture

PURPOSE

The life quality of cervical cancer patients is severely compromised due to the vaginal stump contracture after surgery combined with radiotherapy. Therefore, our study focuses on ameliorating or preventing postoperative vaginal contracture. The objectives of this study were (1) to evaluate the method of ileal graft with vascular pedicle to extend the length of vagina and (2) to investigate the effect of the operation to prevent vaginal stump contracture after cervical cancer surgery combined with radiotherapy.

METHODS

Twenty-five patients with vaginal stump contracture after cervical cancer radical resection with sequential radiotherapy were recruited for the study between 2011 and 2014. The therapy includes releasing the adhesion between vaginal stump and rectum as well as bladder, resecting the vaginal stump but reserving the exterior orifice of vagina, and extending the vaginal length using vascularized ileal graft.

RESULTS

No postoperative complications such as infection and bleeding were observed in all 25 patients. The patients were satisfied with the length and width of vagina after extension; the discharge of reconstructed vagina was acceptable. All patients had sexual intercourse on the follow-up examination, and five patients complained of vaginal bleeding during or after sexual intercourse, although no abnormality was found on colposcopy.

CONCLUSIONS

The patients demonstrated a high level of safety, efficacy, and satisfaction with the ileal-vaginal extension for treating vaginal stump contracture after cervical cancer surgery combined with radiotherapy, suggesting that this method is valid for broad clinical application to improve the life quality of cervical cancer patients after surgery.