A fertility-sparing alternative to radical hysterectomy: how many patients may be eligible?

doi:10.1016/j.ygyno.2004.07.060

Gynecologic Oncology

Volume 95, Issue 3, December 2004, Pages 534-538

https://doi.org/10.1016/j.ygyno.2004.07.060 Get rights and content

Abstract

Objective.

To determine the percentage of patients with early-stage cervical cancer who may be eligible for fertility preservation with laparoscopic radical vaginal trachelectomy (LRVT).

Methods.

We retrospectively reviewed the records of patients who underwent a radical hysterectomy for invasive cervical cancer at our institution from 12/85 to 8/01, before our use of LRVT at Memorial Sloan-Kettering Cancer Center. Institutional eligibility criteria for LRVT were applied. Patients ≥40 years of age were considered ineligible.

Results.

We identified 435 patients who had undergone radical hysterectomy for cervical cancer; 186 were age <40 at surgery and constituted our study population. Eighty-nine (48%) patients may have been eligible by our pathologic criteria. In 12 patients, LRVT may have been aborted or altered because of unexpected disease spread.

Conclusion.

A significant number of patients <40 with early-stage cervical cancer may be pathologically eligible for LRVT and should be counseled on this preoperatively.

Introduction

Cervical cancer remains a major problem worldwide; however, in developed countries, screening programs have dramatically reduced the number of new cases. In 2004, there will be an estimated 10,520 new cases of cervical cancer diagnosed in the United States, and 3900 women will die from this disease[1].

The widespread use of cervical cancer screening has resulted in overall younger age and earlier stage at diagnosis. These two factors pose new challenges in the management of this disease. In the United States, the median age of diagnosis for this disease is 47 [2]. Thus, many women of reproductive age will be diagnosed with this disease at an early stage. Early-stage cervical cancer is treatable by either surgical therapy, consisting of radical hysterectomy, or radiation therapy. Neither form of therapy is able to preserve fertility. In the younger patient, surgical therapy is usually preferred in an attempt to preserve ovarian function and avoid any long-term effects of radiation.

Fertility issues will become more pronounced in the management of cervical cancer as more women decide to delay childbearing. According to the U.S. Census Bureau, 28/1000 and 10/1000 women will give birth to their first child between the ages of 30–34 and 35–39, respectively [3]. The diagnosis of invasive cervical cancer in a nulliparous patient is a challenging situation. In 1987, the French surgeon Dargent [4] developed a fertility-sparing surgical approach for use in the treatment of these patients. Initially called the radical trachelectomy, this procedure is currently performed with laparoscopic pelvic lymphadenectomy and is called the laparoscopic radical vaginal trachelectomy (LRVT). In a small retrospective series, LRVT appears to have similar efficacy as radical hysterectomy in the management of early-stage disease [5]. However, this is a relatively new procedure that is not widely offered; therefore, many women of reproductive age with early-stage cervical cancers may not be presented with LRVT as a treatment option.

The purpose of this retrospective study is to determine the percentage of patients with early-stage cervical cancer who were treated with radical hysterectomy but who may have been eligible for fertility preservation with LRVT, had this technique been available at the time of their treatment.

Section snippets

Materials and methods

We conducted a retrospective chart review of patients who underwent radical hysterectomy for invasive cervical cancer at Memorial Sloan-Kettering Cancer Center (MSKCC) between December 1985 and August 2001. Laparoscopic radical vaginal trachelectomy was not offered at our institution until after August 2001. Chart review included patient age, International Federation of Gynecology and Obstetrics (FIGO) stage, tumor histology, tumor size, body mass index (BMI), gravidity and parity, and

Results

We identified 435 patients who underwent a radical hysterectomy for cervical cancer at our institution during the 15.5-year study period. One hundred and eighty-six (43%) patients were under age 40 at the time of their surgery, and they constitute our study population. Tumor characteristics are listed in Table 2. Of the study population, 174 (94%) patients met the histologic criterion for eligibility for LRVT.

One hundred patients had tumors less than 2 cm. Of these 100, however, one patient had

Discussion

The widespread use of cervical cancer screening will result in an increasing numbers of patients of reproductive age being diagnosed with early-stage cervical cancer. This situation, combined with the increasing incidence of delayed childbearing in developed countries, will undoubtedly produce complex disease management situations. In Surveillance, Epidemiology, and End Results (SEER) data for the year 2000, 27.9% of all patients diagnosed with invasive cervical cancer will be less than 40

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Cited by (140)

Oncologic and Fertility Outcomes After Simple Trachelectomy in Women with Early Cervical Cancer
2024, Journal of Minimally Invasive Gynecology
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.
Descriptive retrospective analysis of patient records and evaluation of questionnaires.
2 gynecologic oncologic centers, surgeries performed by one surgical team.
36 women with early-stage cervical cancer undergoing ST.
Laparoscopic assisted simple vaginal trachelectomy.
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.
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.
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.
Fertility-sparing surgery vs standard surgery for early-stage cervical cancer: difference in 5-year life expectancy by tumor size
2024, American Journal of Obstetrics and Gynecology
Cervical cancer incidence among premenopausal women is rising, and fertility-sparing surgery serves as an important option for this young population. There is a lack of evidence on what tumor size cutoff should be used to define candidacy for fertility-sparing surgery.
We sought to describe how the association between fertility-sparing surgery (compared with standard surgery) and life expectancy varies by tumor size among patients with cervical cancers measuring ≤4 cm in largest diameter. Our secondary objective was to quantify the probability of undergoing adjuvant radiotherapy among patients who underwent fertility-sparing surgery as a function of tumor size.
We identified patients in the National Cancer Database aged ≤45 years, diagnosed with stage I cervical cancer with tumors ≤4 cm between 2006 and 2018, who received no preoperative radiation or chemotherapy, and who underwent either fertility-sparing surgery (cone or trachelectomy, either simple or radical) or standard surgery (simple or radical hysterectomy) as their primary treatment. Propensity-score matching was performed to compare patients who underwent fertility-sparing surgery with those who underwent standard surgery. A flexible parametric model was employed to quantify the difference in life expectancy within 5 years of diagnosis (restricted mean survival time) based on tumor size among patients who underwent fertility-sparing and those who underwent standard surgery. In addition, among those who underwent fertility-sparing surgery, a logistic regression model was used to explore the relationship between tumor size and the probability of receiving adjuvant radiation.
A total of 11,946 patients met the inclusion criteria of whom 904 (7.6%) underwent fertility-sparing surgery. After propensity-score matching, 897 patients who underwent fertility-sparing surgery were matched 1:1 with those who underwent standard surgery. Although the 5-year life expectancy was similar among patients who had fertility sparing surgery and those who had standard surgery regardless of tumor sizes, the estimates of life-expectancy differences associated with fertility-sparing surgery were more precise among patients with smaller tumors (1-cm tumor: restricted mean survival time difference, −0.10 months; 95% confidence interval, −0.67 to 0.47) than among those with larger tumors (4-cm tumor: restricted mean survival time difference, −0.11 months; 95% confidence interval, −3.79 to 3.57). The probability of receiving adjuvant radiation increased with tumor size, ranging from 5.6% (95% confidence interval, 3.9–7.9) for a 1-cm tumor to 37% (95% confidence interval, 24.3–51.8) for a 4-cm tumor.
Within 5 years of diagnosis, young patients with stage I cancers measuring ≤4 cm had similar survival outcomes after either fertility-sparing surgery or standard surgery. However, because few patients with tumors >2 cm underwent fertility-sparing surgery, a clinically important survival difference could not be excluded in this population.
Role of minimally invasive surgery in gynecologic malignancies
2023, DiSaia and Creasman Clinical Gynecologic Oncology
Minimally invasive surgery (MIS) is practiced by more than 90% of gynecologic oncologists. Knowledge of anatomy, the disease process, and surgical technique is key during these complicated surgical procedures. Several studies have shown that 10 to 20 cases are needed to gain proficiency with a certain procedure. MIS reduces blood loss, transfusions, length of hospital stay, and wound complications without compromising adequacy of the procedure or staging even in (extremely) morbidly obese patients. Survival outcomes for endometrial and ovarian cancer are similar after MIS and laparotomy, while survival outcomes with MIS have been shown to be worse for cervical cancer. Several safe methods exist to extract an enlarged uterus after MIS. Morcellation is not recommended when there is suspicion or proven preinvasive or invasive disease. Laparoscopy can be used in ovarian cancer to assess the extent of disease and chance of complete debulking surgery. MIS in advanced or recurrent ovarian cancer and its utilization in interval debulking is still under investigation, and prospective trials to confirm safety and feasibility are ongoing.
ADC and kinetic parameter of primary tumor: Surrogate imaging markers for fertility-sparing vaginal radical trachelectomy in patients with stage IB cervical cancer
2022, European Journal of Radiology
Citation Excerpt :
To select the VRT eligible candidates, several indicators such as histologic type of the tumor, tumor size, cervical stroma invasion depth, nodal status and free endocervical margin should be assessed [10,11]. However, some factors such as nodal involvement and free endocervical margin are evaluated intraoperatively and confirmed postoperatively [3], which poses a risk of aborting the planned surgery or even resorting to a second surgery [12,13]. Tumor size and cervical stroma invasion depth can be detected by magnetic resonance imaging (MRI).
To investigate the role of ADC and kinetic parameters derived from DCE-MRI in selecting eligible candidates for fertility-sparing vaginal radical trachelectomy (VRT). Method: Female patients with FIGO stage IB cervical cancers between March 2019 and January 2022 were retrospectively included. All patients underwent hysterectomy and bilateral lymphadenectomy. According to the surgical pathology, the study population was divided into VRT-eligible group and VRT-ineligible group. ADC, semi-quantitative and quantitative kinetic parameters of the primary tumor were compared between the two groups. Logistic regression analysis was used to determine the independent predictors for VRT eligibility and ROC curve was used to evaluate the predictive performance. Results: 19 patients were deemed eligible for VRT and 50 were ineligible. Compared with VRT-eligible group, time to peak and ADC were significantly lower in VRT-ineligible group (P = 0.004 and 0.001, respectively) while volume fraction of plasma (V_p) was higher in VRT ineligible group (P = 0.001). ADC and V_p were independent predictors for VRT eligibility. Combining V_p and ADC yielded the highest area under the ROC curve of 0.853 compared with that of 0.766 for V_p and 0.764 for ADC, though marginal differences were found (P = 0.109 and 0.078, respectively). Conclusions: ADC and the kinetic DCE-MRI parameter V_p can be used as surrogate markers to select eligible candidates for fertility-sparing VRT.
Fertility preservation in cervical cancer, analysis of 30 years of practice and immersion in future developments
2022, Gynecologie Obstetrique Fertilite et Senologie
La stratégie de préservation de fertilité (PF) dans le cancer du col de l’utérus est challengée depuis plusieurs années et une désescalade thérapeutique semble s’imposer. Dans ce contexte, nous avons évalué les résultats oncologiques, de fertilité et obstétricaux des techniques chirurgicales réalisées dans notre centre en vue d’une PF.
Cet essai uni centrique rétrospectif a inclus 75 patientes, prises en charge à l’institut Gustave Roussy entre 1995 et 2020, pour un cancer de col (stade IB1 FIGO 2018) et ayant conduit un projet de préservation de la fertilité après un bilan pré-thérapeutique approfondi. L’objectif d’un tel recueil était d’appréhender nos résultats sur la fertilité et les issues obstétricales et les corréler aux données oncologiques et enfin d’évaluer l’évolution de nos pratiques chirurgicales.
Cinquante quatre patientes ont bénéficié d’une trachélectomie élargie, aucune atteinte ganglionnaire n’a été constatée. 1 patiente a reçu un traitement complémentaire en post opératoire ne permettant pas de préserver sa fertilité. Le taux de récidive était de 4,8 % (4/75) avec un décès décrit. 31 grossesses ont été obtenues soit un taux de grossesse de 50 %. 74 % des grossesses ont été obtenues spontanément et 60 % des grossesses ont été conduites à terme.
Nos résultats sont similaires à ceux de la littérature. Malgré un projet de préservation de fertilité seulement la moitié des patientes a pu obtenir une grossesse.
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.
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.
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.
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.
Radical vaginal trachelectomy
2021, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
In contrast, other papers include women with a disease stage that most national guidelines suggest should be selected for upfront chemoradiotherapy [5,6,13]. One paper [6] reported that where it is possible to define from the published literature, only 72% of women who had RVT performed had stage 1bi disease [1,14–47]. Therefore, data need to be interpreted with regard to this subject.
Radical vaginal trachelectomy (RVT) is the oldest fertility-sparing procedure for stage 1b cervical cancer. For that reason, there are more published data for RVT than for all the other radical trachelectomy approaches. However, there are no randomised controlled studies between RVT and radical hysterectomy proving the comparability of survival and no randomised controlled studies comparing a vaginal approach with open, standard laparoscopy and robotic approaches. This article intends to describe the case selection, the procedure and outcomes for RVT.

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A fertility-sparing alternative to radical hysterectomy: how many patients may be eligible?

Abstract

Objective.

Methods.

Results.

Conclusion.

Introduction

Section snippets

Materials and methods

Results

Discussion

Lancet

Am. J. Obstet. Gynecol.

BJOG

Am. J. Obstet. Gynecol.

Gynecol. Oncol.

Am. J. Obstet. Gynecol.

Cancer statistics, 2004

CA Cancer J. Clin.