Oncological and obstetrical outcomes after neo-adjuvant chemotherapy followed by fertility-sparing surgery in patients with cervical cancer ≥2 cm

Abstract

ObjectiveThere is significant debate between up-front radical trachelectomy versus neo-adjuvant chemotherapy before fertility-sparing surgery in patients with tumors ≥2 cm. The aim of this study was to report on the oncological and obstetrical outcome of neo-adjuvant chemotherapy followed by fertility-sparing surgery, in patients diagnosed with cervical cancer ≥2 cm.MethodsThis was a retrospective review of patients diagnosed with cervical cancer measuring ≥2 cm to ≤6 cm, who were scheduled to undergo neo-adjuvant chemotherapy before fertility-sparing surgery, at six institutions from four Latin American countries between February 2009 and February 2019. Data collected included: age, International Federation of Gynecology and Obstetrics (FIGO) 2009 stage, histology, tumor size, pre-treatment imaging work-up, chemotherapy agents and number of cycles, toxicity, clinical and imaging response rate, type of fertility-sparing surgery, pathology results, timing of lymphadenectomy, follow-up time, and obstetrical and oncological outcomes.ResultsA total of 25 patients were included, with a median age of 27 years (range 20–37): 17 patients had stage IB1, 7 had stage IB2 cervical cancer, and 1 patient had stage IIA1 (FIGO 2009); 23 patients had squamous cell carcinoma and 2 patients had adenocarcinoma. The median number of chemotherapy cycles was 3 (range 3–6) and no toxicity grade 3–4 was reported. Lymphadenectomy was performed before chemotherapy in 6 (24%) patients. After neo-adjuvant chemotherapy 20 patients were scheduled for radical trachelectomy (11 abdominal and 9 laparoscopic) and 5 patients for conization. After surgery, no residual disease was found in 11 patients (44%). Fertility was preserved in 23 patients (92%) and 10 patients became pregnant (43.5%). After a median follow-up time of 47 months (13–133), 3 patients had recurrent disease (3/23=13%), 2 were alive without disease, and 1 patient had disease at last contact.ConclusionNeo-adjuvant chemotherapy followed by fertility-sparing surgery is feasible in well selected patients with cervical tumors ≥2 cm. Future studies should focus on the timing of lymphadenectomy and type of cervical surgery.

Neoadjuvant Chemotherapy Prior Fertility-Sparing Surgery in Women with FIGO 2018 Stage IB2 Cervical Cancer: A Systematic Review

“…Data are not mature yet to favor lymphadenectomy prior over after NACT in FS treatment. In the study by Rendón et al, recurrences occurred in up to 14% of patients who underwent a pre-NACT lymphadenectomy versus 12.8% in those with a post-NACT lymphadenectomy [51]. In our review, among patients who underwent retroperitoneal staging pre-NACT, two recurrences were reported, but such an approach was far less common (25 patients).…”

“…In our review, among patients who underwent retroperitoneal staging pre-NACT, two recurrences were reported, but such an approach was far less common (25 patients). Using NACT to treat metastatic and micro-metastatic surgery prior to FS might be a sensible option to downstage disease and allow more patients to proceed with fertility preservation [51].…”

Fertility-sparing surgery after neo-adjuvant chemotherapy in women with cervical cancer larger than 4 cm: a systematic review

“…The full-text screening excluded 10 studies: six did not include tumors >4 cm,13–18 two had duplication of information,19 20 one included a patient with lymph node metastases on pre-surgical PET-CT,21 and in one fertility-preserving surgery was not possible in any patient. Finally, 11 studies met the selection criteria12 22–31 (see Figure 1).…”

“…Lymphadenectomy prior to chemotherapy could select a proportion of patients with lymph node disease not detected in the images and reduce the number of women eligible for fertility preservation. However, the rate of lymph node disease in post-chemotherapy lymphadenectomy is between 4.6% and 8.3%,26 29 which could indicate that the lymph node status is susceptible to downstaging with chemotherapy.…”

Fertility Sparing Treatment in Gastric-Type Endocervical Carcinoma

“…The benefit of tumor downsizing with regard to prognosis is considered as controversial. However, it has been documented in numerous retrospective studies [8,9] and is being investigated in prospective trials, NCT00039338, NCT04016389 [10,11].…”