Cervical Cancer Patients: Need Not Forgo Fertility
Radical vaginal trachelectomy offers a select group of cervical cancer patients an alternative to traditional radical hysterectomy. The author examines studies that have shown positive oncologic and childbearing outcomes for reproductive-age patients desiring future fertility.
Site recurrence by size and LVSI*
| UTERUS | PELVIS | DISTANT | TOTAL | |
|---|---|---|---|---|
| Size | ||||
| ≤2 cm (n=125) | 0 | 1 (0.8%) | 1 (0.8%) | 2 (1.6%) |
| >2 cm (n=19) | 0 | 2 (10.5%) | 0 | 2 (10.5%) |
| LVSI | ||||
| No (n=92) | 0 | 0 | 0 | 0 |
| Yes (n=36) | 0 | 3 (8.3%) | 1 (2.8%) | 4 (11.1%) |
| LVSI=lymph-vascular space involvement | ||||
| *Neuroendocrine tumors excluded | ||||
Reproductive outcome
Most researchers have reported that the majority of women attempting to conceive have been successful, and that most pregnancies result in a live birth (Table 4). The rate of second-trimester loss is clearly elevated in women who have undergone radical vaginal trachelectomy. The likely reason: the development of subclinical chorioamnionitis due to an inadequate mucus plug and exposure of the membranes to vaginal flora. To combat this problem, Dargent began performing the Saling procedure at 14 weeks’ gestation.2 This entails approximating the vaginal mucosa over the cervix to provide a barrier to ascending infections. Since performing this technique, Dargent has not observed any cases of second-trimester loss. To date, this technique has not been adopted by other medical centers.
TABLE 4
Reproductive outcome
| LYON N=71 | QUEBEC N=43 | TORONTO N=53 | LOS ANGELES N=20 | LONDON N=9 | TOTAL N=196 | |
|---|---|---|---|---|---|---|
| No. pregnancies | 44 (27)† | 15 (11) | 9 (7)† | 3 (3)† | 7 (4) | 78 |
| Live births | 23 | 8 | 5 | 3‡ | 3 | 42 |
| Neonatal deaths | 0 | 1 | 0 | 0 | 0 | 1 |
| First-trimester loss | 6 | 3 | 2 | 0 | 3 | 14 |
| TAB | 3 | 0 | 0 | 0 | 0 | 3 |
| Ectopic | 1 | 0 | 0 | 0 | 0 | 1 |
| Second-trimester loss | 8 | 2 | 0 | 1 | 1 | 12 |
| Pregnancy ongoing | 3 | 1 | 2 | 0 | 0 | 6 |
| Numbers in parentheses represent number of women who were able to achieve a pregnancy | ||||||
| *5 pregnancies at the time of RVT | ||||||
| †1 pregnancy at the time of RVT | ||||||
| ‡1 set of twins | ||||||
| TAB=therapeutic abortion | ||||||
Conclusion
Based on the available data, the recurrence rate for women with squamous and adenocarcinomas appears to be low and comparable to that observed in women undergoing radical hysterectomy. Women with lesions larger than 2 cm or whose tumors have invaded the lymph-vascular space have a higher rate of recurrence, though not necessarily higher than if they had undergone radical hysterectomy.8,9
However, this data must be interpreted with caution. The majority of recurrences reported have been located in the pelvis, raising the concern that the parametrial resection at the time of radical trachelectomy may be inadequate. Yet, recurrences after radical hysterectomy also tend to be local rather than distant in non-irradiated patients.9,10 Also, the follow-up for women undergoing radical trachelectomy has been relatively short, and the number of women with lesions larger than 2 cm who have undergone this procedure is small. Thus, it is difficult to draw conclusions about the safety and efficacy of radical vaginal trachelectomy in this group.
Nonetheless, this technique appears to be a reasonable option for women with early-stage cervical cancer who desire future fertility. Among the almost 200 cases reported, the cancer recurrence rate is low, and viable pregnancies are clearly possible. However, longer follow-up is desirable. To meet this need, centers performing the procedure are forming a registry to better track both oncologic and reproductive outcomes. Further, more research is needed as to whether the Saling procedure will improve reproductive outcome and whether women with lesions larger than 2 cm and/or tumors invading the lymph-vascular space are at greater risk of recurrence with radical trachelectomy than if they had undergone radical hysterectomy.
At present, I offer radical vaginal trachelectomy to reproductive-age women with lesions 2 cm or smaller who are extremely desirous of future fertility. If the lesion is larger than 2 cm but is distal so that clearance appears feasible, I inform patients that there is limited data available regarding outcome, especially if LVSI is present.
The author reports no financial relationship with any companies whose products are mentioned in this article.
