Simple conization and lymphadenectomy for the conservative treatment of stage IB1 cervical cancer. An Italian experience
Highlights
► We proposed ultra-conservative surgery for IB1 cervical cancer. ► Pregnancies are possible with a low risk of abortion and preterm labor. ► Oncologic safety is reasonable if patients are carefully selected (tumor size < 2 cm).
Introduction
Cervical cancer in fertile age is becoming more and more common in the last two decades. Increased chances of early diagnosis by Pap smear and colposcopy, women's awareness of early symptoms and the diffusion of the oncologic cultural background into the most part of gynecologists are all circumstances that explain the increased diagnosis of small (≤ 2 cm) cervical tumors in childbearing age, often in nulliparous patients. Approximately 40% of women diagnosed with cervical cancer are of reproductive age [1]. This leads to the request of a conservative policy to manage such lesions. Radical trachelectomy [2] and chemo-conization [3], [4] proved to be effective methods to treat safely these cancers, but with some negative issues: pregnancies after trachelectomy carry a severe obstetric morbidity as about one third of them ends with first or second trimester miscarriage or premature labor [5], while the latter strategy implies the use of neoadjuvant chemotherapy that often discourages patients to accept such a proposal.
Simple conization, with or without lymphadenectomy, represents a plausible treatment scheme for managing stage IA1-2 tumors in patients desiring offspring. However its curative potential has not been widely exploited as regards stage IB1 lesions. Actually, recent studies suggest that, in selected circumstances, patients with stage IB1 disease undergoing radical hysterectomy could have been safely cured by simple hysterectomy and even by cervical conization [6], [7], [8], [9], [10], [11]. Covens et al. [6] suggested that the incidence of parametrial involvement in patients with tumor size < 2 cm, negative pelvic lymphnodes and depth of invasion < 10 mm was only 0.6%. Similar data were eventually reported by Steed et al. [7] and Wright et al. [8]. In this perspective, an analysis of the 22 recurrences reported among 548 cases (4%) treated by radical trachelectomy confirmed that the risk factors for recurrence were lesion size > 2 cm, presence of lymph-vascular space involvement and depth of stromal invasion > 10 mm [5]. We may hypothesize that cervical conization could represent a safe treatment in selected cases, that in turn may improve the obstetrical as well as surgical outcome, in terms of reduced risk of urologic morbidity.
The present series is aimed to assess the oncologic and obstetrics results of conservative treatment of stage IB1 cervical cancers with pathological negative lymphnodes by conization alone.
Section snippets
Materials and methods
Since December 1995 to January 2010 women referred for a chance of conservative therapy were managed in two different ways. Patients with a tumor diameter between 2 and 3 cm were proposed to undergo neoadjuvant chemotherapy and conization with pelvic lymphadenectomy, as described in a previous paper [3]. Patients with stage IB1 disease smaller than 2 cm and patients referred by other hospitals after diagnosis of stage IB1 carcinoma performed by cervical conization (therefore with their disease
Results
Thirty-seven women accepted the conservative approach. One patient was excluded because of grossly positive lymphnodes during lymphadenectomy, therefore 36 patients were studied. Median age was 31 years (range 24–40) and median tumor size was 11.7 mm (range 8–25 mm). Adenocarcinoma was present in 12 cases (33%) and grade 3 neoplasia in 5 (14%). Lymph-vascular space involvement was detected in five patients (14%). Eleven (30.5%) had already a child while two had experienced an early abortion and a
Discussion
Since 1994, when Dargent first described and introduced into the clinical practice the indications and technique of radical trachelectomy, radical hysterectomy does not represent the only way to treat surgically young patients with stage IB1 cervical cancer and a chance of preserving their fertility can be offered. Nowadays radical trachelectomy represents the most common strategy to manage these cases conservatively but it shows some relevant limits. First of all, its technique is not part of
Conflict of interest statement
The authors declare that there are no conflicts of interest.
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