Neoadjuvant chemotherapy in early-stage cervical cancer (<2 cm) before conization for fertility preservation: is there any advantage over upfront conization?

Abstract

BackgroundNeoadjuvant chemotherapy before fertility-sparing surgery is an accepted option for patients with cervical tumors between 2 cm and 4 cm. There is a paucity of data regarding its role in patients with tumors &lt;2 cm. Our objective was to compare the oncological and obstetrical outcomes between patients who underwent neoadjuvant chemotherapy before cervical conization versus upfront cervical conization in patients with cervical cancer with tumors &lt;2 cm.MethodsWe conducted a systematic literature review and searched MEDLINE, EMBASE, and CINAHL (from 1995 to March 2020) using the terms: uterine cervix neoplasms, cervical cancer, fertility-sparing surgery, fertility preservation, conization, cone biopsy, and neoadjuvant chemotherapy. We included manuscripts with information on patients with tumor size &lt;2 cm, lymph node status, follow-up, oncological and obstetrical outcome, and toxicity related to neoadjuvant chemotherapy. We excluded review articles or articles with duplicated patient information.ResultsWe identified 12 articles, including 579 patients. For final analysis, 261 patients met inclusion criteria. The most common histology was non-squamous cell carcinoma (62%). Median follow-up time was 63.5 (range 7–122) months for the neoadjuvant chemotherapy group and 48 (range 12–184) months for the upfront cervical conization group. There was no difference in either overall survival (neoadjuvant chemotherapy group 100% vs upfront cervical conization 99.7%, p=0.79) or disease-free survival (neoadjuvant chemotherapy 100% vs upfront cervical conization 98.9%, p=0.59) between the groups. Fertility preservation rate was 81.4% versus 99.1% (p&lt;0.001) favoring upfront cervical conization. No statistically significant differences were seen in live birth rate or pregnancy loss. Also, we found that all neoadjuvant chemotherapy patients reported chemotherapy-related toxicity (30.7% grade 3 and 69.2% grade 1–2).ConclusionsThere was no difference in disease-free survival or overall survival between patients who underwent neoadjuvant chemotherapy followed by conization and upfront cervical conization. Patients who underwent upfront cervical conization had a higher fertility preservation rate.

Fertility-Sparing and Less Radical Surgery for Cervical Cancer

“…While neoadjuvant chemotherapy is accepted as a treatment option for tumor sizes between 2 and 4 cm, there is less data regarding its role in tumors < 2 cm. A 2021 systematic review by Noll et al sought to compare oncologic and obstetric outcomes for patients who received neoadjuvant chemotherapy before cervical conization versus upfront conization in patients with a tumor size < 2 cm [ 39 ]. They reviewed data from 261 patients with a median follow-up time of 63.5 months and found no difference in disease-free survival or overall survival between the two groups.…”

“…They reviewed data from 261 patients with a median follow-up time of 63.5 months and found no difference in disease-free survival or overall survival between the two groups. They did note, however, that patients who underwent upfront cervical conization had a higher rate of fertility preservation (99.1%) compared to an 81.4% fertility preservation rate in the neoadjuvant chemotherapy group [ 39 ]. There were no statistically significant differences in live birth rate or pregnancy loss [ 39 ].…”

“…They did note, however, that patients who underwent upfront cervical conization had a higher rate of fertility preservation (99.1%) compared to an 81.4% fertility preservation rate in the neoadjuvant chemotherapy group [ 39 ]. There were no statistically significant differences in live birth rate or pregnancy loss [ 39 ].…”