Fertility Sparing Surgery in Early Cervical Cancer Today and Tomorrow

Overview

Objective:
Describtion and evaluation of proposed protocol for conservative, fertility sparing surgeries in the treatment of early stages of cervical cancer and its comparison to most frequently used protocols regarding its reproductive and oncological outcomes.

Design:
Prospective clinical study.

Setting:
Department of Obstetrics and Gynecology, Charles University Prague, 2^nd Medical Faculty, University Hospital Motol.

Patients and Methods:
24 patients that fitted into the inclusion criteria were recruited in the study (6 in stage T1A2 and 18 T1B1). Inclusion criteria were: tumor less than 20 mm in largest diameter, less than 1⁄2 of the stromal invasion, SCC serum levels within normal range, signed informed consent. Minimum follow up was 24 months. Described therapeutic protocol, evaluation of oncological and reproductive outcomes and comparison with different fertility sparing regimens were performed.

Results:
In four cases (16.7%) peroperative histopatghological evaluation (frozen section: FS) detected metastatic involvement of lymphatic nodes. In one case (4.1%) following 14 months since initial surgery, reccurent disease in uterine isthmus was detected. The patient underwent chmotherapy and she is 36 months in complete remission. In the series of 15 women planning pregnancy 11 subjects become pregnant so far. Eight deliveries occurred (one in 24th week of gestation – 650g, one in 34w – 2240g, one in 36w – 2700g and five between 37 - 39w). Only one newborn was delivered in the cathegory of extreme prematurity.

Conclusion:
Sentinel node detection involving peroperative histopathological evaluation followed by subsequent serial processing and together with 2-step therapeutic management increases efectivity of fertility sparing surgeries. Less radical surgery on uterine cervix: reconisaton (in stage IA2) or simple trachelectomy (in early stage T1B1) with negative finding after laparoscopic lymph node dissection has comparative results with radical trachelectomy and abdominal radical trachelectomy. Pregnancy rates and pregnancy outcomes particularly regarding in term delivery is the best after treatment of early stages of cervical cancer using proposed protocol, while very promising results are published in studies with radical vaginal trachelectomy as well. Results published for the patients treated with abdominal radical trachelectomy are unsatisfactory.

Key words:
cervical cancer, sentinle lymph nodes, laparoscopic lymphadenectomy, trachelectomy, pregnancy