Current knowledge on fertility-sparing treatment of cervical cancer patients


Authors: L. Fricová ;  J. Sláma
Authors‘ workplace: Gynekologicko-porodnická klinika 1. LF UK a VFN v Praze
Published in: Ceska Gynekol 2022; 87(5): 362-370
Category: Review Article
doi: 10.48095/cccg2022362

Overview

Introduction: Cervical cancer directly affects the reproductive function of women of childbearing age. Up to one-third of the disease is dia­gnosed in women younger than 45 years of age, who may still have open reproductive plans. Therefore, in recent years, there has been increasing interest in performing fertility-sparing treatment (FST), which aims to preserve fertility while achieving the same oncologic safety as radical surgical treatment. Objective: To summarize the current knowledge on FST in women with early stages of cervical cancer. Methods: Review of published literature on the topic using medical databases. Results: FST is reserved for patients with HPV-associated cervical cancer up to stage IB with negative nodes. Conservative procedures (conization and simple vaginal trachelectomy) and radical trachelectomy are available. Conservative procedures for tumors ≤ 2 cm have comparable oncological outcomes as radical treatment with a significantly lower rate of perinatological complications. On average, 55% of patients become pregnant after treatment and of these, on average 70% give birth to a live newborn. Approximately 38% of deliveries are preterm, most often after radical trachelectomy. The most common postoperative complication with direct impact on fertility is cervical stenosis. Conclusion: In a selected group of patients with tumors up to 2 cm, FST is a safe procedure with good perinatological outcomes. However, it remains unclear whether it is safe to offer this treatment to patients with larger tumors. The use of neoadjuvant chemotherapy followed by conservative surgery is a promising approach but requires further validation in clinical trials.

Keywords:

cervical cancer – trachelectomy – fertility-sparing treatment – conization


Sources

1. Dušek L, Mužík J, Kubásek M et al. Epidemiologie zhoubných nádorů v České republice. 2022 [online]. Dostupné z: http: //www.svod.cz/?sec=analyzy.

2. Rob L, Charvát M, Robová H et al. Fertilitu zachovávající operace u časného stadia karcinomu děložního hrdla dnes a zítra. Ceska Gynekol 2006; 71 (4): 302–307.

3. Chovanec J, Náležinská M. Přehled dia­gnostiky a léčby karcinomu děložního hrdla. Onkologie 2014; 8 (6): 269–274.

4. Cibula D, Pötter R, Planchamp F et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology guidelines for the management of patients with cervical cancer. Int J Gynecol Cancer 2018; 28 (4): 641–655. doi: 10.1097/IGC.0000000000001 216.

5. Cibula D, Ungár L, Svárovský J et al. Abdominální radikální trachelektomie – technika a zkušenosti. Ceska Gynekol 2005; 70 (2): 117–122.

6. Rob L, Skapa P, Robova H. Fertility-sparing surgery in patients with cervical cancer. Lancet Oncol 2011; 12 (2): 192–200. doi: 10.1016/S1470-2045 (10) 70084-X.

7. Dargent D, Martin X, Sacchetoni A et al. Lapa­roscopic vaginal radical trachelectomy: a treatment to perserve the fertility of cervical carcinoma patients. Cancer 2000; 88 (8): 1877–1882.

8. Kocian R, Slama J, Fischerova D et al. Micrometastases in sentinel lymph nodes represent a significant negative prognostic factor in early-stage cervical cancer: a single-institutional retrospective cohort study. Cancers (Basel) 2020; 12 (6): 1438. doi: 10.3390/cancers12061 438.

9. Cibula D, Dostálek L, Jarkovsky J et al. Post-recurrence survival in patients with cervical cancer. Gynecol Oncol 2022; 164 (2): 362–369. doi: 10.1016/j.ygyno.2021.12.018.

10. Li F, Gimbrere K, Gelber R et al. Outcome of pregnancy in survivors of Wilms‘ tumor. JAMA 1987; 257 (2): 216–219.

11. Rob L, Skapa P, Robova H. Fertility-sparing surgery in patiens with cervical cancer. Lancet Oncol 2011; 12 (2): 192–200. doi: 10.1016/S1470- 2045 (10) 70084-X.

12. Hawkins M, Smith R. Pregnancy outcomes in childhood cancer survivors: probable effects of abdominal irradiation. Int J Cancer 1989; 43 (3): 399–402. doi: 10.1002/ijc.2910430309.

13. Pridjian G, Rich N, Montag A. Pregnancy hemoperitoneum and placenta percreta in a patient with previous pelvic irradiation and ovarian failure. Am J Obstet Gynecol 1990; 162 (5): 1205–1206. doi: 10.1016/0002-9378 (90) 90 018-3.

14. Schmeler K, Pareja R, Lopez Blanco A et al. ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer. Int J Gynecol Cancer 2021; 31 (10): 1317–1325. doi: 10.1136/ijgc-2021-002921.

15. Freitag P. Jaká je adekvátní velikost konusu?. Prakt Gyn 2016; 20 (1): 12–14.

16. Sláma J, Runnebaum I, Scambia G et al. Fertility sparing surgery in cervical cancer patients outside controlled trials – a multicenter retrospective cohort trial (CEEGOG Cx-03; ENGOT-CX14). ESGO eAcademy 2021: 343768

17. Kenney LB, Nicholson HS, Brasseux C et al. Birth defects in offspring of adult survivors of childhood acute lymphoblastic leukemia. A childrens cancer group/national institutes of health report. Cancer 1996; 78 (1): 169–176. doi: 10.1002/ (SICI) 1097-0142 (19960701) 78: 1<169::: AID-CNCR23>3.0. CO; 2-X.

18. Signorello LB, Mulvihill JJ, Green DM et al. Stillbirth and neonatal death in relation to radiation exposure before conception: a retrospective cohort study. Lancet 2010; 376 (9741): 624–630. doi: 10.1016/S0140-6736 (10) 60752-0.

19. Dargent D, Martin X, Sacchetoni A et al. Laparoscopic vaginal radical trachelectomy: a treatment to preserve the fertility of cervical carcinoma patients. Cancer 2000; 88 (8): 1877–1882.

20. Hruda M, Robova H, Rob L et al. Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: oncological outcomes. Gynecol Oncol 2021; 163 (1): 100–104. doi: 10.1016/j.ygyno.2021.07.031.

21. Bentivegna E, Maulard A, Pautier P et al. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: a systematic review of the literature. Fertil Steril 2016; 106 (5): 1195.e5–1211.e5. doi: 10.1016/ j.fertnstert.2016.06.032.

22. Sehnal B, Kmoníčková E, Sláma J et al. Současný FIGO staging karcinomu děložního hrdla a léčba jednotlivých stadií. Klin Onkol 2019; 32 (3): 224–231. doi: 10.14735/amko2019224.

23. Nezhat C, Roman RA, Rambhatla A et al. Reproductive and oncologic outcomes after fertility-sparing surgery for early stage cervical cancer: a systematic review. Fertil Steril 2020; 113 (4): 685–703. doi: 10.1016/j.fertnstert.2020.02. 003.

24. Ramirez P, Frumovitz M, Pareja R et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med 2018; 379 (20): 1895–1904. doi: 10.1056/NEJM oa1806395.

25. Nick AM, Frumovitz MM, Soliman PT et al. Fertility sparing surgery for treatment of early-stage cervical cancer: open vs. robotic radical trachelectomy. Gynecol Oncol 2012; 124 (2): 276–280. doi: 10.1016/j.ygyno.2011.09. 035.

26. Beiner M, Hauspy J, Rosen B et al. Radical vaginal trachelectomy vs. radical hysterectomy for small early stage cervical cancer: a matched case-control study. Gynecol Oncol 2008; 110 (2): 168–171. doi: 10.1016/j.ygyno.2008.04. 027.

27. Bentivegna E, Gouy S, Maulard A et al. Oncological outcomes after fertility-sparing surgery for cervical cancer: a systematic review. Lancet Oncol 2016; 17 (6): e240–e253. doi: 10.1016/S1470-2045 (16) 30032-8.

28. Plante M, Gregoire J, Renaud MC et al. The vaginal radical trachelectomy: an update of a series of 125 cases and 106 pregnancies. Gynecol Oncol 2011; 121 (2): 290–297. doi: 10.1016/ j.ygyno.2010.12.345.

29. Viveros-Carreño D, Rodriguez J, Rendon Pereira GJ et al. Fertility-sparing surgery after neo-adjuvant chemotherapy in women with cervical cancer larger than 4 cm: a systematic review. Int J Gynecol Cancer 2022; 32 (4): 486–493. doi: 10.1136/ijgc-2021-003297.

30. Maneo A, Sideri M, Scambia G et al. Simple conization and lymphadenectomy for the conservative treatment of stage IB1 cervical cancer. An Italian experience. Gynecol Oncol 2011; 123 (3): 557–560. doi: 10.1016/j.ygyno.2011.08.009.

31. Lindsay R, Burton K, Shanbhag S et al. Fertility conserving management of early cervical cancer: our experience of LLETZ and pelvic lymph node dissection. Int J Gynecol Cancer 2014; 24 (1): 118–123. doi: 10.1097/IGC.0000000000000 023.

32. Li X, Xia L, Chen X et al. Simple conization and pelvic lymphadenectomy in early-stage cervical cancer: a retrospective analysis and review of the literature. Gynecol Oncol 2020; 158 (2): 231–235. doi: 10.1016/j.ygyno.2020.05. 035.

33. Slama J, Fischerova D, Zikan M et al. Sensitivity of follow-up methods in patients after fertility-sparing surgery for cervical cancers. Int J Gynecol Cancer 2017; 27 (1): 147–153. doi: 10.1097/IGC.0000000000000835.

34. Tomao F, Maruccio M, Preti EP et al. Conization in early stage cervical cancer: pattern of recurrence in a 10-year single-institution experience. Int J Gynecol Cancer 2017; 27 (5): 1001–1008. doi: 10.1097/IGC.0000000000000 991.

35. Šimják P, Cibula D, Pařízek A et al. Management of pregnancy after fertility-sparing surgery for cervical cancer. Acta Obstet Gynekol Scand 2020; 99 (7): 830–838. doi: 10.1111/aogs.13917.

36. Speiser D, Köhler C, Schneider A et al. Radical vaginal trachelectomy: a fertility-preserving procedure in early cervical cancer in young women. Dtsch Arztebl Int 2013; 110 (17): 289–295. doi: 10.3238/arztebl.2013.0289.

37. Selo-Ojeme D, Ind T, Shepherd J. Isthmic stenosis following radical trachelectomy. J Obstet Gynaecol 2002; 22 (3): 327–328. doi: 10. 1080/01443610252971302.

38. Kyrgiou M, Athanasiou A, Paraskevaidi M et al. Adverse obstetric outcomes after local treatment for cervical preinvasive and early invasive disease according to cone depth: systematic review and meta-analysis. BMJ 2016; 354: i3633. doi: 10.1136/bmj.i3633.

39. Šimják P, Pařízek A, Sláma J. Prenatální péče o těhotnou ženu po fertilitu-zachovávajícím výkonu pro karcinom děložního hrdla. Ceska Gynekol 2020; 85 (6): 422–429.

Labels
Paediatric gynaecology Gynaecology and obstetrics Reproduction medicine

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