Reproductive and oncologic outcomes after fertility-sparing surgery for early stage cervical cancer: a systematic review

Abstract

This review sought to evaluate the current literature on reproductive and oncologic outcomes after fertility-sparing surgery for early stage cervical cancer (stage IA1-IB1) including cold-knife conization/simple trachelectomy, vaginal radical trachelectomy, abdominal radical trachelectomy, and laparoscopic radical trachelectomy with or without robotic assistance. A systematic review using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist to evaluate the current literature on fertilitysparing surgery for early stage cervical cancer and its subsequent clinical pregnancy rate, reproductive outcomes, and cancer recurrence was performed. Sixty-five studies were included encompassing 3,044 patients who underwent fertility-sparing surgery, including 1,047 pregnancies with reported reproductive outcomes. The mean clinical pregnancy rate of patients trying to conceive was 55.4%, with the highest clinical pregnancy rate after vaginal radical trachelectomy (67.5%). The mean live-birth rate was 67.9% in our study. Twenty percent of pregnancies after fertility-sparing surgery required assisted reproductive technology. The mean cancer recurrence rate was 3.2%, and the cancer death rate was 0.6% after a median follow-up period of 39.7 months with no statistically significant difference across surgical approaches. Fertility-sparing surgery is a reasonable alternative to traditional radical hysterectomy for early-stage cervical cancer in women desiring fertility preservation. Vaginal radical trachelectomy had the highest clinical pregnancy rate, and minimally invasive approaches to fertility-sparing surgery had equivalent oncologic outcomes compared with an abdominal approach. The results of our study allow for appropriate patient counseling preoperatively and highlight the importance of a multidisciplinary approach to achieve the best outcomes for each patient. (Fertil Steril Ò 2020;113:685-703. Ó2020 by American Society for Reproductive Medicine.

Central Pathology Review in SENTIX, a Prospective Observational International Study on Sentinel Lymph Node Biopsy in Patients with Early-Stage Cervical Cancer (ENGOT-CX2)

“…In cases of major deviations, SLN assessment was completed according to the protocol at the central laboratory, without the need of additional sample transportation back to the referring sites. Patients scheduled for fertility-sparing surgery were eligible in the trial since they could profit from intraoperative triage the most [27][28][29]. The threshold for upper tumor size in fertility-sparing treatment was 2 cm, which corresponds to the recent international recommendations [9].…”

Laparoscopic and Robotic Surgery for Endometrial and Cervical Cancer

“…The MIS approach is associated with lower intraoperative and postoperative morbidity [106,109]. Fertility outcomes with open or MIS (most of the included studies were of laparoscopic surgery) have been reported to be lower than with vaginal trachelectomy [105,110]. In contrast, a large series from an experienced robotics centre has shown a high fertility rate of 81% following robotic radical trachelectomy, associated with a low rate of preterm deliveries.…”

“…A systematic review by Nezhat et al [110] reviewed the current evidence on reproductive and oncological outcomes after fertility-sparing surgery for stage 1A1e1B1 cervical cancer, including cold-knife conisation/simple trachelectomy, vaginal, open and minimally invasive radical trachelectomy with or without robotic assistance. In total, there were 65 studies, encompassing 3044 patients who underwent fertility-sparing surgery, including 1047 pregnancies.…”

First case of four spontaneously conceived successful pregnancies after fertility‐sparing surgery for cervical cancer

“…The risk of recurrence is increased with tumors >2 cm. 2,3 Further contraindications include a history of sterility and age >40-45 years. A laparoscopic nodal staging should be performed primarily, and patients with nodal infiltration need to be managed on an individual basis.…”

“…In a recent meta-analysis that investigated FSS (all types) for early-stage cervical cancer, 3044 patients including 1047 pregnancies were identified. 2 The pregnancy rate of women trying to conceive was 55%. The highest pregnancy rate was found in patients undergoing VRT (67.5%).…”