Abdominal radical trachelectomy: Is it safe for IB1 cervical cancer with tumors ≥ 2 cm?

doi:10.1016/j.ygyno.2013.07.079

Gynecologic Oncology

Volume 131, Issue 1, October 2013, Pages 87-92

https://doi.org/10.1016/j.ygyno.2013.07.079 Get rights and content

Highlights

•
ART could be a safe fertility-sparing option for selected patients with tumors ≥ 2 cm in size.
•
A radical resection of parametrial tissue would be critical to secure oncological safety in patients with tumors ≥ 2 cm.
•
The discrepancy between node assessment in frozen sections and the final pathology is a therapeutic problem and needs further investigation.

Abstract

Objectives

As abdominal radical trachelectomy (ART) has become a favored fertility-sparing procedure, the relative contraindication of a tumor ≥ 2 cm in size has been questioned. The aim of the study was to report the surgical and oncological safety of ART for selected patients with cervical cancer ≥ 2 cm in size.

Methods

We conducted a retrospective review of a prospectively maintained database of patients undergoing ART at our institution from 04/2004 to 01/2013. The largest tumor dimension was determined by physical exam, MRI or final pathology. Clinical and pathological data were tabulated. All patients were followed postoperatively.

Results

Of the 133 patients who underwent planned ART, 62 (46.6%) had tumors ≥ 2 cm in size (2–4 cm). Forty-six patients were documented by exam or MRI, while 16 were documented by pathology reports. The mean age was 30.4 years, and 42 patients (67.7%) were nulliparous. Fifty (80.7%) had squamous carcinoma, 7 (11.3%) had adenocarcinoma and 5 (8%) had adenosquamous carcinoma. Due to frozen-section results, 6 patients (9.7%) underwent an immediate hysterectomy. Due to high-risk features on final pathology, 27 patients (43.5%) were treated with adjuvant chemotherapy (n = 20) or chemoradiation (n = 7). In total, 55 (88.7%) of 62 patients with a tumor ≥ 2 cm in size preserved their fertility potential. Among these patients, 35 underwent ART without further adjuvant treatment. At a median follow-up of 30.2 months, there were no recurrences.

Conclusions

Expanding the ART inclusion criteria to cervical cancers ≥ 2 cm in size allows a fertility-sparing procedure in young women who would have otherwise been denied the option with no apparent compromise in oncological outcome. However, this may result in higher rates of conversion to hysterectomy or the need for adjuvant chemotherapy/or chemoradiation.

Introduction

Women with cervical cancer who have delayed childbearing often have a strong desire for fertility-preserving surgery. Radical trachelectomy (RT) is a viable option for such patients. This novel fertility-sparing surgery has become widely accepted since it was initially developed in 1987 by the French surgeon Daniel Dargent.

For oncological safety, vaginal radical trachelectomy (VRT) is generally limited to cervical cancer with a tumor size less than 2 cm. However, because abdominal radical trachelectomy (ART) can remove a wider portion of parametrial tissue than VRT, it is unclear if it would be safe to expand the ART inclusion criteria to cervical cancer patients with tumors ≥ 2 cm in size. The purpose of this article is to report our experience with ART in cervical cancer patients whose tumors are ≥ 2 cm in size and to describe the surgical and oncological outcomes.

Section snippets

Methods

With institutional review board approval, we conducted a retrospective review of a prospectively maintained database of patients undergoing fertility-sparing ART for cervical cancer at our institution from 04/2004 to 01/2013. If patients met institutional eligibility criteria, which were published previously [1], they were considered eligible for ART with a pelvic lymphadenectomy. This surgical procedure was approved by the institutional review board, and all patients who planned to undergo ART

Results

Between 04/2004 and 01/2013, a total of 133 cervical cancer patients underwent a laparotomy for a planned fertility-sparing abdominal radical trachelectomy and pelvic lymphadenectomy. Of them, 62 patients had a tumor ≥ 2 cm in size, and these 62 patients constitute our study group. Forty-six patients had their tumor size documented by a physical exam or MRI, while 16 patients had it documented on a pathology report from a cone/LEEP/trachelectomy or summation of the tumor size from the cone/LEEP

Discussion

In current gynecological oncology practice, fertility preservation has become a significant and meaningful issue when deciding on how to treat stage IA-IB cervical cancer [4]. For the first time, the 2013 NCCN cervical cancer guidelines separate the treatment of stage I cervical cancer based on the desire for fertility preservation. The guidelines also allow the inclusion of select stage IB1 lesions without a restriction on tumor diameter but with the notation that this approach is most

Conflict of interest statement

The authors have no conflicts of interest to declare.

Acknowledgments

This research is supported by the “Supporting Program for Appropriate Technology” of the Shanghai Health Bureau (SHDC12012215).

References (37)

J. Li et al.
Radical abdominal trachelectomy for cervical malignancies: surgical, oncological and fertility outcomes in 62 patients
Gynecol Oncol
(2011)
A. Sedlis et al.
A randomized trial of pelvic radiation therapy versus no further therapy in selected patients with stage IB carcinoma of the cervix after radical hysterectomy and pelvic lymphadenectomy: a Gynecologic Oncology Group Study
Gynecol Oncol
(1999)
M. Roy et al.
Pregnancies after radical vaginal trachelectomy for early stage cervical cancer
Am J Obstet Gynecol
(1998)
Marie Plante et al.
The vaginal radical trachelectomy: an update of a series of 125 cases and 106 pregnancies
Gynecol Oncol
(2011)
P. Mathevet et al.
Fertility preservation in early cervical cancer
Gynecol Obstet Fertil
(2003)
H. Hertel et al.
Radical vaginal trachelectomy (RVT) combined with laparoscopic pelvic lymphadenectomy: prospective multicenter study of 100 patients with early cervical cancer
Gynecol Oncol
(2006)
M. Plante et al.
Vaginal radical trachelectomy: an oncologically safe fertility-preserving surgery. An updated series of 72 cases and review of the literature
Gynecol Oncol
(2004)
Lukas Rob et al.
Fertility-sparing surgery in patients with cervical cancer
Lancet Oncol
(2011)
H. Nishio et al.
Abdominal radical trachelectomy as a fertility sparing procedure in women with early-stage cervical cancer in a series of 61 women
Gynecol Oncol
(2009 Oct)
A. Covens et al.
How important is removal of the parametrium at surgery for carcinoma of the cervix?
Gynecol Oncol
(2002)

O. Gemer et al.

Can parametrectomy be avoided in early cervical cancer? An algorithm for the identification of patients at low risk for parametrial involvement

Eur J Surg Oncol

(2013 Jan)

M.H. Einstein et al.

Radical vaginal versus abdominal trachelectomy for stage Ib1 cervical cancer: a comparison of surgical and pathologic outcomes

Gynecol Oncol

(2009)

P. Marchiole et al.

Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent’s operation): a comparative study with laparoscopic assisted vaginal radical hysterectomy (LARVH)

Gynecol Oncol

(2007)

W.K. Kinney et al.

Identification of a low-risk subset of patients with stage 1B invasive squamous cancer of the cervix possibly suited to less radical surgery treatment

Gynecol Oncol

(1995)

H. Steed et al.

Early cervical cancer and parametrial involvement: is it significant?

Gynecol Oncol

(2006)

M. Stegeman et al.

The incidence of parametrial tumor involvement in select patients with early cervix cancer is too low to justify parametrectomy

Gynecol Oncol

(2007)

P. Strnad et al.

A prospective study of sentinel lymph node status and parametrial involvement in patients with small tumors volume cervical cancer

Gynecol Oncol

(2008)

L. Rob et al.

A less radical treatment option to the fertility-sparing radical trachelectomy in patients with stage I cervical cancer

Gynecol Oncol

(2008)

Cited by (63)

Robotic versus vaginal radical trachelectomy for reproductive-aged patients with early-stage cervical carcinoma: A multi-center cohort study
2024, Gynecologic Oncology
A randomized non-inferiority trial showed worse survival in women with early-stage cervical cancer treated with radical hysterectomy by minimally invasive approach compared to laparotomy; the impact of surgical approach on survival following radical trachelectomy is unknown.
To examine oncologic outcomes in women with early-stage cervical cancer who underwent robotic or vaginal radical trachelectomy at Canadian cancer centers with the highest volumes of radical trachelectomy procedures.
Retrospective multi-centre cohort analysis which includes patients who had surgery between 2006 and 2019. Women with International FIGO 2009 stage IA-IB cervical cancer who underwent radical trachelectomy and lymph node assessment were grouped by surgical approach (vaginal versus robotic surgery).
A total of 197 patients were included from 4 regional referral centres. 56 women underwent robotic radical trachelectomy and 141 underwent vaginal radical trachelectomy. All patients had lymph node assessment by a minimally invasive technique. Median age was 32 years, median tumor size was 12 mm, and median depth of invasion was 5 mm. Recurrence-free survival was 97% in both groups at a median follow-up of 57 months. On multivariable analysis, after adjusting for previously chosen confounders (high risk pathologic criteria, tumor size, and LVSI) there was no statistically significant difference in PFS between the 2 groups (HR 2.1, 95%CI 0.3–7.1, p = 0.5). Tumor size larger than 2 cm (HR 9.4, 95%CI 2.8–26, p = 0.003) was the only variable predictive of recurrence.
Survival outcomes were excellent in both cohorts of patients undergoing robotic vs. vaginal radical trachelectomy. The surgical approach was not significantly associated with risk of recurrence after adjusting for clinically important confounders.
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.
Neo-adjuvant chemotherapy in fertility-sparing cervical cancer treatment
2021, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
In general, the response rate to neo-adjuvant chemotherapy is approximately 70% [9]. Poor response to neo-adjuvant chemotherapy may be related to worse oncological outcome [10]. Moreover, in patients with positive lymph nodes, higher recurrence rates have been observed [3,11,12].
The current review provides a literature overview of studies assessing the oncological and fertility outcomes of treatment with neo-adjuvant chemotherapy followed by fertility-sparing surgery in patients with cervical cancer >2 cm. Six cohort studies were included showing severe heterogeneity regarding patient selection, chemotherapy regimen, and surgical approach. In total, 111 patients were studied, with overall favorable characteristics. Patients were on average 29 years old, had a tumor of 36 mm, no lymph node metastasis, and response to chemotherapy. In approximately 5-year follow-up, the recurrence rate was 13% (0%–21%) and overall death rate 2.7% (0%–10%). Three patients were alive with recurrent disease (2.7% and 0%–11%). Of the 111 patients, 90 underwent successful fertility-sparing treatment (83%). Roughly one-third conceived and one-fourth had a healthy live-born child. More research is essential to determine proper selection criteria for fertility-sparing treatment of cervical cancer >2 cm and the optimal treatment management.
Fertility-sparing trachelectomy for early-stage cervical cancer: A proposal of an ideal candidate
2020, Gynecologic Oncology
To propose an ideal patient candidate with early-stage cervical cancer for undergoing fertility-sparing trachelectomy.
This nationwide, multicenter, retrospective study was conducted by the Japan Society of Obstetrics and Gynecology involving women aged <45 years with clinical stage I-II cervical cancer who had planned fertility-sparing trachelectomy and pelvic lymphadenectomy between 2009 and 2013 (n = 393). Ideal candidates were defined to have a tumor size of ≤2 cm, no lymph node metastasis, no deep stromal invasion, and no high-risk histology (n = 284, 69.6%). Less-ideal candidates were defined to have any one of these four characteristics (n = 109, 30.4%). Propensity score inverse probability of treatment weighting was used to assess survival outcomes.
Less-ideal candidates were more likely to undergo hysterectomy conversion (22.9% versus 3.2%), receive postoperative radiotherapy (11.9% versus 0.4%), or chemotherapy (32.1% versus 3.2%) compared with ideal candidates (all, P < 0.05). The weighted model revealed that among those who underwent trachelectomy (ideal candidates, n = 275 and less-ideal candidates, n = 84), less-ideal candidates had significantly decreased disease-free survival (5-year rates: 85.5% versus 95.5%; HR 3.93, 95% CI 1.99–7.74; P < 0.001) and cause-specific survival (92.5% versus 98.6%; HR 5.47, 95% CI 1.68–17.8, P = 0.001) compared with ideal candidates. Similarly, less-ideal candidates were significantly associated with decreased disease-free survival compared with ideal candidates among those who were young age, had small tumors or squamous histology, and underwent surgery alone (all, P < 0.05).
Less-ideal candidates had approximately four-fold higher recurrence risk and cancer mortality compared with ideal candidates. Ideal candidates for fertility-sparing trachelectomy for early-stage cervical cancer proposed in our study may be useful as the future framework for developing guidelines for fertility-sparing trachelectomy in Japan.
Fertility-sparing treatment in cancer patients: how can we help in the 21st century?
2024, Russian Journal of Human Reproduction
Fertility sparing therapy in women with lymph node negative cervical cancer >2cm - Oncologic and fertility outcomes of neoadjuvant chemotherapy followed by radical vaginal trachelectomy
2023, International Journal of Gynecological Cancer

View all citing articles on Scopus

View full text

Abdominal radical trachelectomy: Is it safe for IB1 cervical cancer with tumors ≥ 2 cm?

Highlights

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conflict of interest statement

Acknowledgments

Gynecol Oncol

Gynecol Oncol

Am J Obstet Gynecol

Gynecol Oncol

Gynecol Obstet Fertil

Gynecol Oncol

Gynecol Oncol

Lancet Oncol

Gynecol Oncol

Gynecol Oncol

Eur J Surg Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol