Fertility-Sparing Treatment for Early-Stage Cervical Cancer ≥ 2 cm: A Problem with a Thousand Nuances—A Systematic Review of Oncological Outcomes

Abstract

Background Fertility-sparing treatments (FSTs) have played a crucial role in the management of early-stage cervical cancer (ECC). The guidelines have recognized various approaches, depending on the tumor stage and other risk factors such as histotype and lymphovascular positivity. Much more debate has centered around the boundary within which these treatments should be considered. Indeed, these are methods to be reserved for ECC, but tumor size may represent the most significant limitation. In particular, there is no consensus on the strategy to be adopted in the case of ECC ≥ 2 cm. Therefore, this systematic review was to collect the literature evidence regarding the management of these patients. Methods Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the Pubmed and Scopus databases was conducted in April 2022, from the date of the first publication. We made no limitation on the country. We included all studies containing data on disease-free survival, overall survival, recurrence rate (RR), or complete response rate (CRR) to chemotherapy. Results Twenty-six studies fulfilled the inclusion criteria, and 691 patients were analyzed regarding FST. Surgery-based FST showed an RR of between 0 and 42.9%, which drops to 12.9% after excluding the vaginal or minimally invasive approaches. Furthermore, papers regarding FST based on the neoadjuvant chemotherapy (NACT) approach showed a CRR of between 21.4 and 84.5%, and an RR of between 0 and 22.2% Conclusion This paper focused on the significant heterogeneity present in the clinical management of FST of ECC ≥ 2 cm. Nevertheless, from an oncological point of view, approaches limited to the minimally invasive or vaginal techniques showed the highest RR. Vice versa, the lack of standardization of NACT schemes and the wealth of confounders to be attributed to the histological features of the tumor make it difficult, if not impossible, to set a standard of treatment.

Fertility-Sparing Treatment for Early-Stage Cervical Cancer ≥ 2 cm: Can One Still Effectively Become a Mother? A Systematic Review of Fertility Outcomes

“… 28 In a previous review, our group collected the literature evidence regarding managing this type of patient, focusing on oncological outcomes. 5 The results of this work ended in extremely heterogeneous data that reflect current clinical practice. Nevertheless, approaches limited to minimally invasive or vaginal techniques seem to show the highest recurrence rate (RR) 5 and ART seems to be a safer option, according to recent evidence from the LACC trial.…”

“… 5 The results of this work ended in extremely heterogeneous data that reflect current clinical practice. Nevertheless, approaches limited to minimally invasive or vaginal techniques seem to show the highest recurrence rate (RR) 5 and ART seems to be a safer option, according to recent evidence from the LACC trial. 28 On the other hand, some literature reported that despite this oncological safety, ART proved to result in worse pregnancy results.…”

“…In a previous review, we have remarked on the significant heterogeneity present in the clinical management of FST of ECC ≥ 2 cm, focusing mainly on oncological outcomes. 5 However, once oncological safety is demonstrated, it should be crucial to deeply understand the impact those two approaches have on fertility outcomes. The purpose of this review was to compare the rates of pregnancy, live births, and preterm rates for women with ECC ≥ 2 cm treated with surgical FST or NACT approaches.…”

Survival outcomes of abdominal radical hysterectomy, laparoscopic radical hysterectomy, robot-assisted radical hysterectomy and vaginal radical hysterectomy approaches for early-stage cervical cancer: a retrospective study

“…A systematic review and meta-analysis showed that laparo-assisted vaginal radical hysterectomy did not appear to affect DFS and OS in early-stage CC patients, comparing with the open approach group of the LACC trial [ 42 ]. Nevertheless, MIS and vaginal surgery showed the highest recurrence rate compared to ARH for patients with early-stage CC regarding fertility-sparing treatments in tumours > 2 cm in size [ 43 ]. Thus, more studies will be needed to compare the surgical approaches of ARH, LRH, RRH and VRH in the early-stage CC.…”

Whole-tumor histogram analysis of apparent diffusion coefficients for predicting lymphovascular space invasion in stage IB-IIA cervical cancer

“…Moreover, according to the Sedlis criteria, early cervical cancer patients with no lymph node (LN) metastasis but with LVSI require further LN dissection and postoperative radiotherapy to improve survival by eradicating micro-metastases ( 5 , 6 ). In addition, LVSI is an essential factor in the decision-making process for fertility-sparing treatments ( 7 , 8 ). For patients with LVSI who require fertility, a wide resection margin should be performed ( 5 ).…”