Can simple trachelectomy or conization show comparable survival rate compared with radical trachelectomy in IA1 cervical cancer patients with lymphovascular space invasion who wish to save fertility? A systematic review and guideline recommendation

Abstract

ObjectiveThis study aims to analyze the published literatures on the effect of less radical fertility-preserving procedures, such as conization or simple trachelectomy, on oncological outcomes in IA1 cervical cancer patients with lymphovascular space invasion (LVSI) through a systematic-review.MethodsThe EMBASE and MEDLINE databases and Cochrane Library were searched for published studies reporting the oncological outcomes of conization/simple trachelectomy in these patients, through April 2017. The endpoints were recurrence and mortality rates. Data were presented as per the Meta-analysis Of Observational Studies in Epidemiology checklist. Practice guidelines were generated via the Grading of Recommendation, Assessment, Development and Evaluation system.ResultsFrom 6,755 records, 94 full-texts articles were reviewed for eligibility, and five studies were included in this systematic review. All included studies were nonrandomized studies: two case-control studies comparing conization (n = 14) with hysterectomy (n = 24), and the other three were interrupted time series including conization (n = 20) and simple vaginal trachelectomy (n = 59). During the median follow-up duration of 43 months, no recurrence was reported in both conization and simple trachelectomy groups in IA1 patients with LVSI. From three studies reporting the fertility outcomes, the rates of pregnancy, live birth, preterm delivery, and second-trimester miscarriage were 73% (35/48), 64% (32/50), 10% (5/48), and 6% (3/48), respectively.ConclusionResults suggest that simple trachelectomy or conization could be performed for IA1 cervical cancer patients with LVSI who want to preserve fertility, although these results are only based on a small number of nonrandomized studies (recommendation grade 2 = weak; evidence level D = very low). Further randomized trials with long-term study period are needed to address this issue.

Large Conization—Retrospective Monocentric Results for Fertility Preservation in Young Women with Early Stage Cervical Cancer

“…In our study, although the number of patients is less, nine of sixteen women intended to get pregnant (56.2%) and all 9 of them (100%) were able to conceive. There were 4 miscarriages (28.6%), which is in a similar range as described in recent literature [20,23,24]. Despite the rate of spontaneous conceptions was high (71.4%) in our study, 4 patients needed assisted reproductive technology (ART).…”

“…This methodical problem was also shown by Shim et al in a recent systematic review. They demonstrate the problem of analysing recurrence and pregnancy rates in early stage cervical cancer (IA1) with lymphovascular involvement treated by LC or SVT, since most studies were retrospective and of small, nonrandomized numbers [ 24 ]. In this respect, our results may contribute additional clinical data to further evaluate LC as a surgical technique that supports fertility preservation with less cervical trauma but with uncompromised oncological safety.…”

Outcome and Subsequent Pregnancy after Fertility-Sparing Surgery of Early-Stage Cervical Cancers

“…Hartmann et al reported a 7.3% recurrence rate in 41 IA1 patients treated with conization [ 20 ]. However, Shim et al reported that there was no recurrence in a total of 93 patients who underwent conization or simple trachelectomy [ 21 ]. In our series, there was no invasive cancer recurrence in any of the stage IA1 patients.…”

Implications of the new FIGO staging and the role of imaging in cervical cancer

“…It includes removal of the uterine cervix and vaginal cuff, and parametrial resection, followed by the creation of an isthmic vaginal anastomosis. 9 The current National Comprehensive Cancer Network (NCCN) recommendation for fertility-sparing trachelectomy is Stage IB1 tumour. 10 Tumour size of less than 2 cm is also included as eligibility criteria for fertility-sparing management of cervical cancer, along with histology (squamous cell carcinoma (SCC), adenocarcinoma and adenosquamous carcinoma), tumour-to-internal os distance of more than 1 cm, cervical stromal invasion less than 50%, lack of parametrial invasion, and lack of LN metastasis (Figure 2).…”