Cervical Cancer and Fertility-Sparing Treatment

Abstract

Radical hysterectomy with pelvic node dissection is the standard treatment for early-stage cervical cancer. However, the latter can be diagnosed at a young age when patients have not yet achieved their pregnancy plans. Dargent first described the vaginal radical trachelectomy for patients with tumors <2 cm. It has since been described a population of low risk of recurrence: patients with tumors <2 cm, without deep stromal infiltration, without lymphovascular invasion (LVSI), and with negative lymph nodes. These patients can benefit from a less radical surgery such as conization or simple trachelectomy with the evaluation of the pelvic node status. Tumors larger than 2 cm have a higher risk of recurrence and their treatment is a challenge. There are currently two options for these patients: abdominal radical trachelectomy or neoadjuvant chemotherapy (NACT), followed by fertility-sparing surgery. All patients who wish to preserve their fertility must be referred to expert centers.

Neoadjuvant chemotherapy in fertility-sparing management of FIGO 2018 stage IB2 cervical cancer

“…In such cases, in order to preserve the uterus, a simple or radical trachelectomy could then be proposed, as fertility-sparing surgery. 1 2 The size of the tumor and the presence of LVSI are associated with higher risk of relapse 1 2 . The ConCerv trial was recently published and found a rate of recurrence of 3% in patients undergoing a simple cone/trachelectomy with a tumor size < 20 mm without LVSI ( one local recurrence in 31 stage IB1 cases) 3 .…”

“…The ongoing GOG 278 trial (that includes patients treated with simple cone/trachectomy or simple hysterectomy) will provide information on quality of life in patients undergoing conservative management of early disease (NCT01649089). A relapse rate of 4% and a death rate of approximately 2% have been reported after radical trachelectomy by the vaginal approach 1 2 . However, these ultra-conservative strategies could not be safely proposed in FIGO 2018 stage IB2 disease (with further foci of LVSI) due to significant increase of recurrence.…”

“…The first option is abdominal radical trachelectomy (by an open, laparoscopic, or robotic-assisted approach). The abdominal approach allows extending the radicality of the paracervical resection 1 2 . Several series of abdominal radical trachelectomy for the management of FIGO 2018 stage IB2 cervical cancer have been published, with recurrence rates ranging from 2.6% to 10.4% 1 2 .…”

“…The abdominal approach allows extending the radicality of the paracervical resection 1 2 . Several series of abdominal radical trachelectomy for the management of FIGO 2018 stage IB2 cervical cancer have been published, with recurrence rates ranging from 2.6% to 10.4% 1 2 . However, notable morbidities were observed, particularly following the open approach.…”

“…These included deep sepsis and/or uterine necrosis 2 . Furthermore, obstetric results were disappointing, particularly after abdominal radical trachelectomy by the open approach (perhaps an impact of the laparotomy on subsequent fertility or uterine artery ligation ) 1 2 . Conversely, follow-up time in series reporting on the abdominal approach are shorter .…”