Elsevier

Gynecologic Oncology

Volume 121, Issue 2, 1 May 2011, Pages 290-297
Gynecologic Oncology

The vaginal radical trachelectomy: An update of a series of 125 cases and 106 pregnancies

https://doi.org/10.1016/j.ygyno.2010.12.345Get rights and content

Abstract

Objective

To review our first consecutive 125 vaginal radical trachelectomies (VRT) to assess the oncologic, fertility and obstetrical outcomes.

Methods

Data from our prospective database was used to identify all VRT planned between October 1991 to March 2010 in patients with early-stage cervical cancer (stages IA, IB and IIA). Chi-square test, Fisher's exact test and Student t-test were used to compare baseline characteristics and Kaplan–Meier survival curves were constructed and compared with the use of the log-rank test.

Results

During the study period, 140 VRT were planned and 125 were performed. The median age of the patients was 31 and 75% were nulliparous. The majority of the lesions were stage IA2 (21%) or IB1 (69%) and 41% were grade 1. In terms of histology, 56% were squamous and 37% were adenocarcinomas. Vascular space invasion was present in 29% of cases, and 88.5% of the lesions measured ≤ 2 cm. The mean follow-up was 93 months (range: 4–225 months). There were 6 recurrences (4.8%) and 2 deaths (1.6%) following VRT. The actuarial 5-year recurrence-free survival was 95.8% [95% CI: 0.90–0.98], whereas it was 79% [95% CI: 0.49–0.93] in the group where the VRT was abandoned (p = 0.001). Higher tumor grade, LVSI and size > 2 cm appeared to be predictive of the risk of abandoning VRT (p = 0.001, p = 0.025 and p = 0.03 respectively). Tumor size > 2 cm was statistically significantly associated with a higher risk of recurrence (p = 0.001). In terms of obstetrical outcome, 58 women conceived a total of 106 pregnancies. The first and second trimester miscarriage rates were 20% and 3% respectively, and 77 (73%) of the pregnancies reached the third trimester, of which 58 (75%) delivered at term. Overall, 15 (13.5%) patients experienced fertility problems, 40% of which were due to cervical factor. Twelve (80%) were able to conceive, the majority with assisted reproductive technologies.

Conclusion

VRT is an oncologically safe procedure in well-selected patients with early-stage disease. Lesion size > 2 cm appears to be associated with a higher risk of recurrence and a higher risk of abandoning the planned VRT. Fertility and obstetrical outcomes post VRT are excellent.

Research Highlights

►VRT offers excellent oncology outcome and preserves fertility in most patients. ►Lesions > 2 cm are associated with a higher risk of recurrence.

Introduction

With childbearing being one of the most important goals in life, fertility preservation has become a very important component of the overall quality of life of young cancer survivors. Neglected for a long time, the issue of fertility preservation is receiving more attention and is now studied in a more comprehensive way. In 2006, the American Cancer Society has made recommendations to encourage physicians to discuss fertility issues in reproductive age cancer patients prior to initiating cancer treatments [1]. The psychosocial impact of cancer-related infertility in women treated for gynecologic malignancies is significant with a high proportion of these women experiencing feelings of depression, grief, stress and sexual dysfunction [2], [3]. Recent data confirms that the emotional and physical impact of impaired or loss of fertility can be long lasting [4].

The most common cancers in women aged less than 40 are breast cancer, melanoma, cervical cancer, non-Hodgkin's lymphoma and leukemia [5]. According to the SEER data, up to 42% of all cervical cancers are diagnosed in women prior to the age of 45 [6]. Data from the Sloan-Kettering indicate that up to 40% of women who have undergone a radical hysterectomy at their center would have been eligible for a radical trachelectomy [7]. Therefore, particularly in countries where cervical cancer screening is in place, a significant proportion of cervical cancer is diagnosed at an early stage, frequently in women aged less than 40, such that a significant proportion of these patients may be interested in a treatment modality that preserves fertility without jeopardizing oncologic outcome.

The radical trachelectomy is now an accepted treatment modality for the surgical management of early-stage cervical cancer in women wishing to preserve fertility. The oncologic and obstetrical results that have accumulated over the last 2 decades have confirmed a recurrence rate < 5% and promising obstetrical results [8].

We have previously reported our oncologic and obstetrical results in our first 72 patients and our first 50 pregnancies [9], [10]. We now report on a larger cohort of 140 patients including 106 pregnancies. We wish to summarize our experience and provide key figures for clinicians when counseling patients interested in this procedure and for patients in order to have realistic expectations when considering this fertility-preserving option.

Section snippets

Material and methods

This is a prospective series of 140 consecutive planned vaginal radical trachelectomies in women with a diagnosis of early-stage cervical cancer wishing to preserve their fertility potential over an 18-year period, from October 1991 to March 2010. All records were kept prospectively in a computerized database. The technique of the vaginal radical trachelectomy has been described thoroughly elsewhere [11].

All patients were aware that the trachelectomy procedure could be abandoned if metastatic

Patients and tumor characteristics

A VRT was offered to 140 women with early-stage cervical cancer during an 18-year period but the procedure was actually performed in 125 (89%). The median age was 31 (range: 20–42). Table 1 summarizes tumor characteristics, with comparison between patients who had the planned trachelectomy and patients who did not. The majority of patients (69%) had stage IB1 disease and 21% had stage IA2 disease. Only 7 patients (5%) had stage IA1 disease but all had vascular space invasion, and 3 had stage

Oncologic outcome

We report one of the largest single institution series of vaginal radical trachelectomies. Compared to our previous report, tumor characteristics are largely unchanged except for a 4% increase in the proportion of adenocarcinomas, 8% more LVSI and 8% more stage IB1 (Table 1). Morbidity of the procedure remains low (5.7%) (Table 2) and compares favorably with data reported in other series [13], [14], [15].

Conflict of interest statement

The authors declare that there are no conflicts of interest.

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