Central pelvic recurrence 7 years after radical vaginal trachelectomy

BACKGROUND: We report a case of central pelvic recurrence 7 years after radical vaginal trachelectomy for adenocarcinoma of the cervix. CASE: A 30-year-old woman was treated by radical vaginal trachelectomy and bilateral pelvic lymph node dissection (a fertility sparing procedure) in 1996 for cervical cancer. Pathology demonstrated a well differentiated, stage 1B1 adenocarcinoma. She presented 7 years later with a central pelvic recurrence measuring 30 mm in width. She subsequently underwent radical hysterectomy for central clearance and did not require post-operative radiotherapy. CONCLUSIONS: Should selected patients who were initially treated by radical trachelectomy for early stage cervical cancer, in particular those with adenocarcinoma (as 50% of recurrences have been reported in this group of patients), be offered hysterectomy once child bearing is complete?     

Systematic comparison of radical vaginal trachelectomy and radical hysterectomy in the treatment of early-stage cervical cancer

Objective

To review the effects of radical vaginal trachelectomy (RVT) and radical hysterectomy (RH) on overall progression-free survival rate, and intraoperative and postoperative complications in patients with cervical cancer (FIGO stage IA-IB1).

Methods

Electronic searches for studies of RVT and RH in the treatment of cervical cancer between 1994 and January 2010 were made on MEDLINE, the Cochrane Library, the China National Knowledge Infrastructure, and the Wan Fang dissertation database.

Results

No significant differences were found between RVT and RH in 5-year overall survival rate (relative risk [RR] 0.97; 95% confidence interval [CI], 0.93-1.02); 5-year progression-free survival rate (RR 0.99; 95% CI, 0.95-1.02); intraoperative complications (RR 1.99; 95% CI, 0.61-6.52)]; and postoperative complications (RR 0.36; 95% CI, 0.10-1.27). There were fewer blood transfusions (RR 0.33; 95% CI, 0.12-0.90), less blood loss, and shorter hospital stays in patients undergoing RVT.

Conclusion

Radical vaginal trachelectomy should be considered as a viable treatment option for young patients with early cervical cancer (FIGO stage IA-IB1) who wish to preserve their fertility.     

A fertility-preserving option in early cervical carcinoma: laparoscopy-assisted vaginal radical trachelectomy and pelvic lymphadenectomy

OBJECTIVE: Laparoscopic vaginal radical trachelectomy is a fertility-preserving alternative to radical hysterectomy or chemoradiation in young women with stage IA2 to IB cervical cancers. The aim of this study is to describe the feasibility and outcome of laparoscopic radical vaginal trachelectomy and pelvic lymphadenectomy in women treated with early cervical cancers who wish to maintain fertility. STUDY DESIGN: From August 2000 through December 2004, 16 patients were offered this procedure. Patients were selected for this treatment on the basis of favorable cervical tumors and a desire to maintain fertility. Laparoscopic pelvic lymphadenectomies were performed in all patients. Vaginal radical trachelectomy was performed immediately if removed lymph nodes were negative. Obstetrical and oncological outcomes were evaluated. RESULTS: Sixteen women underwent this procedure. The mean operative time was 142 min (115-178 min), with a mean blood loss of 180 ml (120-230 ml), and the average hospital stay was 6.7 days. No intraoperative or postoperative complications occurred. With an average follow-up of 28.2 months, there have been no recurrences. Five pregnancies have subsequently occurred, with two third-trimester deliveries, two miscarriages at 24 and 26 weeks' gestation, and one patient is currently 18 weeks' pregnant. CONCLUSIONS: Laparoscopy-assisted radical vaginal trachelectomy is an adequate treatment, with its minimally invasive procedure and shorter recovery time, for early-stage cervical cancer in women who wish to preserve fertility. However, fertility issues remain the largest unanswered problem with this technique.     

经阴道广泛性宫颈切除术及广泛性子宫切除术注意事项

文章介绍了经阴道广泛性宫颈切除术及经阴道广泛性子宫切除术的手术注意事项,分析了术中可能出现并发症的原因及其预防措施。     

Less radical fertility-sparing surgery than radical trachelectomy in early cervical cancer

The purpose of this pilot study was to determine feasibility and safety of a novel and less radical fertility-preserving surgery; laparoscopic lymphadenectomy with sentinel lymph node identification (SLNI) followed by large cone or simple trachelectomy. Obstetrical and oncologic outcomes were evaluated. Twenty-six patients (6-IA2, 20-IB1) selected on basis of favorable cervical tumor characteristics and the desire to maintain fertility underwent laparoscopic SLNI, frozen section (FS), and a complete pelvic lymphadenectomy as first step of treatment. All of nodes were submitted for microscopic evaluation (sentinel nodes for ultramicrostaging). After a 7-day interval, large cone or simple vaginal trachelectomy was performed in patients with negative nodes. The average of sentinel nodes per side was 1.50 and the average of total nodes was 28.0. Four FS were positive (15.4%). In these cases, Wertheim radical hysterectomy type III was immediately performed. We had no false-negative SLN neither on FS nor on final pathology assessment. Median follow-up was 49 months (18-84). One central recurrence (isthmic part of uterus) was observed 14 months after surgery. This patient was treated with radical chemoradiotherapy, and there was no evidence of the disease 36 months after treatment. Fifteen women planned pregnancy, 11 women became pregnant (15 pregnancies), and 7 women delivered eight children (one in 24 weeks, one in 34 weeks, one in 36 weeks, and five between 37 and 39 weeks). We conclude that lymphatic mapping and SLNI improves safety in this fertility sparing surgery. Large cone or simple trachelectomy combined with laparoscopic pelvic lymphadenectomy can be a feasible method with a high successful pregnancy rate.     

The vaginal radical trachelectomy: an update of a series of 125 cases and 106 pregnancies

Objective

To review our first consecutive 125 vaginal radical trachelectomies (VRT) to assess the oncologic, fertility and obstetrical outcomes.

Methods

Data from our prospective database was used to identify all VRT planned between October 1991 to March 2010 in patients with early-stage cervical cancer (stages IA, IB and IIA). Chi-square test, Fisher's exact test and Student t-test were used to compare baseline characteristics and Kaplan-Meier survival curves were constructed and compared with the use of the log-rank test.

Results

During the study period, 140 VRT were planned and 125 were performed. The median age of the patients was 31 and 75% were nulliparous. The majority of the lesions were stage IA2 (21%) or IB1 (69%) and 41% were grade 1. In terms of histology, 56% were squamous and 37% were adenocarcinomas. Vascular space invasion was present in 29% of cases, and 88.5% of the lesions measured ≤ 2 cm. The mean follow-up was 93 months (range: 4-225 months). There were 6 recurrences (4.8%) and 2 deaths (1.6%) following VRT. The actuarial 5-year recurrence-free survival was 95.8% [95% CI: 0.90-0.98], whereas it was 79% [95% CI: 0.49-0.93] in the group where the VRT was abandoned (p = 0.001). Higher tumor grade, LVSI and size > 2 cm appeared to be predictive of the risk of abandoning VRT (p = 0.001, p = 0.025 and p = 0.03 respectively). Tumor size > 2 cm was statistically significantly associated with a higher risk of recurrence (p = 0.001). In terms of obstetrical outcome, 58 women conceived a total of 106 pregnancies. The first and second trimester miscarriage rates were 20% and 3% respectively, and 77 (73%) of the pregnancies reached the third trimester, of which 58 (75%) delivered at term. Overall, 15 (13.5%) patients experienced fertility problems, 40% of which were due to cervical factor. Twelve (80%) were able to conceive, the majority with assisted reproductive technologies.

Conclusion

VRT is an oncologically safe procedure in well-selected patients with early-stage disease. Lesion size > 2 cm appears to be associated with a higher risk of recurrence and a higher risk of abandoning the planned VRT. Fertility and obstetrical outcomes post VRT are excellent.     

Isolated recurrence at the residual uterine cervix after abdominal radical trachelectomy for early cervical cancer

BACKGROUND: We report an isolated recurrence at the residual cervix shortly after abdominal radical trachelectomy for cervical cancer. CASE: A 34-year-old woman underwent radical abdominal trachelectomy and pelvic lymphadenectomy for FIGO stage IB1 squamous cell cervical cancer. The tumor measured 10 mm in maximum diameter with 4 mm of invasion. Histology showed lymph vascular space involvement with no infiltration of adjacent structures and no pelvic lymph node metastases. Tumor-free resection margins exceeded 15 mm. At the 6-month follow-up examination, cervical cytology showed cells suspicious for recurrent cervical cancer. Abdominal hysterectomy was performed and histology showed an isolated 3-mm recurrence in the residual cervix. The patient is free of disease 8 months after hysterectomy. CONCLUSION: Recurrence at the residual cervix is a potential risk of abdominal trachelectomy for early cervical cancer. Patients should be counseled accordingly and followed closely.     

A model for prediction of parametrial involvement and feasibility of less radical resection of parametrium in patients with FIGO stage IB1 cervical cancer

Objective

The objective of this study was to evaluate the potential risk factors associated with parametrial invasion and to identify preoperatively a subgroup of patients at low risk for parametrial involvement who could be appropriate candidates for less radical surgery in FIGO stage IB1 cervical cancer.

Methods

We retrospectively reviewed the medical records of 317 FIGO stage IB1 cervical cancer patients undergoing class III radical hysterectomy and bilateral pelvic lymphadenectomy. Clinocopathologic factors associated with parametrial invasion were analyzed and the risk criteria predicting parametrial involvement were calculated using a logistic regression model.

Results

Of 317 patients, 17 patients (5.4%) had parametrial involvement. Tumor size > 3 cm (OR, 3.80; [95% CI, 1.19-12.06]; p = 0.02) and pelvic lymph node metastasis (OR, 3.02; [95% CI, 1.04-8.79]; p = 0.04) were independent pathologic factors for parametrial invasion on multivariate analysis. Significant preoperative factors associated with parametrial involvement were tumor size > 3 cm (OR, 4.29; [95% CI, 1.43-12.89]; p < 0.01) and serum SCC Ag level > 1.40 ng/mL (OR, 3.27; [95% CI, 1.11-9.69]; p = 0.03). We identified 185 low-risk (tumor size ≤ 3 cm and SCC ≤ 1.4 ng/mL) and 132 high-risk (tumor size > 3 cm and/or SCC > 1.4 ng/mL) patients. The rates of parametrial involvement in low- and high-risk patients were 1.1% and 11.4%, respectively (p < 0.01).

Conclusions

In this dataset, a model using tumor size and SCC Ag level is highly predictive of parametrial involvement in patients with stage IB1 cervical cancer and may identify candidates for less radical parametrial resection.     

First case of a centropelvic recurrence after radical trachelectomy: literature review and implications for the preoperative selection of patients

BACKGROUND: To report the first case of a centropelvic recurrence in a patient who underwent a radical trachelectomy (RT) for a stage IB1 cervical carcinoma. CASE: A 32-year-old woman presented with a stage IB1 adenocarcinoma that was treated by radical trachelectomy. The tumor measured 21 x 20 mm. Minimal lymphatic space involvement was observed close to the tumor associated with 30 negative nodes and free margins. The upper free margin measured only 5 mm. Twenty-six months after the surgical procedure, the patient became pregnant. Clinical examination and pap smears were normal 2 months prior. During the first trimester, ultrasonography depicted a suspicious lesion in the bladder. Abdomino-pelvic magnetic resonance imaging (MRI) demonstrated a suspicious 20-mm tumor in the bladder associated with suspicious common iliac nodes. Cystoscopy and biopsies were carried out which confirmed recurrent disease. The patient received external radiation therapy combined with concomitant chemotherapy. CONCLUSIONS: More data are required to establish what is the safety distance between the tumor and the uterine transection. A distance of 5 mm or less is likely to be too limited for radical trachelectomy to be accepted as treatment for cervical cancer.     

Fertility-sparing radical abdominal trachelectomy for cervical carcinoma: technique and review of the literature

OBJECTIVES: Radical trachelectomy has emerged as a reasonable fertility-sparing operation for selected patients with stage I cervical cancer. The purpose of this report is to describe our technique of radical abdominal trachelectomy, a fertility-sparing operation in women with cervical cancer, and review the current literature on this procedure. METHODS: A review of a prospectively maintained database of all fertility-sparing radical trachelectomy procedures performed at our institution. RESULTS: Between 11/01 and 3/06, we performed a total of 42 fertility-preserving radical trachelectomies with pelvic lymphadenectomy for women with invasive cervical cancer. We had previously reported on 2 pediatric abdominal trachelectomies, which are excluded from this report. Five of the remaining 40 cases had undergone a radical abdominal trachelectomy, and 35 cases were performed laparoscopically with a radical vaginal approach. The characteristics of the 5 adult patients who underwent abdominal radical trachelectomy included stage IB1 disease in all cases, a mean age of 36 years (range, 33-39), and a mean estimated blood loss of 280 ml (range, 50-400); 1 patient with squamous cell carcinoma needed completion radical hysterectomy at the time of trachelectomy due to disease extending into the endometrium, and 1 patient needed postoperative chemoradiation due to a positive parametrial lymph node. The remaining 3 patients resumed normal menstruation postoperatively. All patients remain disease-free at the time of this report. The only remaining uterine blood supply in these patients are the utero-ovarian vessels. There were no postoperative complications, and transurethral Foley catheters were removed in all cases within 2 weeks. CONCLUSIONS: Radical abdominal trachelectomy with pelvic lymphadenectomy is a feasible operation for selected women with stage I cervical cancer who desire to preserve reproductive function. Menstruation and reproductive function may be preserved after bilateral uterine vessel ligation. The procedure expands the inclusion criteria of radical vaginal trachelectomy to patients with distorted cervicovaginal anatomy in which the vaginal approach may not be feasible.     

Three classes of radical vaginal hysterectomy for treatment of endometrial and cervical cancer

OBJECTIVES: The aims of this study were to (1) describe three types of extended vaginal hysterectomy with different degree of radicality, (2) to identify possible indications for each one of them, and (3) to encourage individualization of the treatment, with special reference to the reevaluation of the role of vaginal surgery in gynecologic oncology. STUDY DESIGN: The surgical-anatomic principles of radical vaginal surgery and the techniques of three increasingly extended vaginal hysterectomies are illustrated. Possible indications are pointed out on the basis of our personal experience from previously published retrospective studies. RESULTS: Class I extended vaginal hysterectomy allows the “en bloc” dissection of the uterus along with the upper third of vagina and both the adnexa. The parametria are not removed. This procedure has proved to be of value for treatment of stage I endometrial cancer. In the class II extended vaginal hysterectomy the distal tract of the anterior and posterior parametria are preserved, whereas the cardinal ligament is entirely removed. This operation has shown promising results for treatment of stage IB-IIA cervical cancer of small volume while reducing the incidence of bladder and rectal dysfunctions. The class III procedure includes the complete removal of the parametria (anterior, lateral, and posterior). This operation has been shown to provide a high rate of cure for stage IB-IIA cervical cancer. CONCLUSIONS: In view of the several advantages of vaginal surgery, this approach should be considered in the individualized treatment of selected cases of endometrial and cervical cancers. The three classes of radical vaginal hysterectomy allow tailoring the type of vaginal operation to the clinical and physical characteristics of the patients. The combined use of extraperitoneal or laparoscopic lymphadenectomy would considerably extend the indications for radical vaginal operations. (Am J Obstet Gynecol 1996;175:1576-85.)     

Abdominal radical trachelectomy: two new surgical techniques for the conservation of uterine arteries

The objective of this study was to develop two new techniques for the conservation of uterine arteries in abdominal radical trachelectomy. Abdominal trachelectomy with conservation of uterine arteries was performed in two patients with cervical carcinoma. In the first case, the internal iliac artery was divided at 2.0 cm from the bifurcation of the common iliac artery. The internal iliac artery and uterine artery were skeletonized along their lengths to the lateral cervix. The dissected internal iliac artery was then reanastomosed following the radical trachelectomy. In the second case, the technique was similar to that of the first except that the internal iliac artery was not divided. Intraoperative observation and postoperative color Doppler ultrasound were used to confirm the patency of the uterine arteries. The operative time of the two patients was 390 min. and 350 min, respectively. Doppler flow studies demonstrated that the uterine arteries were patent in both cases. Resistance index of the left and the right uterine artery was 0.58 and 0.61, respectively, in the first case, and 0.60 and 0.63, respectively, in the second case. Reanastomosis of the internal iliac arteries or skeletonization of the internal iliac arteries are both feasible methods to conserve the uterine arteries during abdominal radical trachelectomy.     

Role of the two-point pull-up technique for treating the uterine arteries during radical hysterectomy and trachelectomy

Objectives

To introduce a safe and reliable method for the management of peripheral vessels around the uterine artery during abdominal radical hysterectomy or abdominal radical trachelectomy.

Study design

From 2007 to 2011, 102 patients with invasive cervical cancer underwent an abdominal radical hysterectomy. In 48 operations in 2007–2009, we performed the conventional radical hysterectomy, in which we ligated and cut the uterine arteries at their origin, and we divided the anterior leaf of the vesico-uterine ligament by blindly inserting scissors into the ureteral tunnel, pushing the ureter laterally from the cervix. In 54 operations in 2009–2011, we pulled up the origin and the bifurcation of the uterine artery using vessel tape, skeletonized the uterine artery and directly divided the superficial uterine vein, superior vesical vein and ureteric branch of the uterine artery. We also performed four radical trachelectomies using the two point pull-up method. We investigated whether this method was useful for the management of peripheral vessels around the uterine artery.

Results

The mean total blood loss in the two point pull-up method group (485 ± 270 ml) was significantly lower than that in the conventional surgery group (686 ± 554 ml) (p < 0.05). The mean length of the operation in the two point pull-up method group (481 ± 53 min) was not significantly different from the conventional surgery group (497 ± 74 min) (p = 0.111). The mean number of dissected lymph nodes in the two point pull-up method group (37.2 ± 11.6) was not significantly different from that in the conventional method group (34.4 ± 10.2) (p = 0.096). The overall survival and progression-free survival were also not substantially different between the two groups. In the radical trachelectomy, the mean blood loss was 377.5 ± 185.6 ml and the mean duration of surgery was 520.0 ± 48.5 min using the two point pull-up method. We were able to preserve both uterine arteries without accidental injury or disruptive bleeding. All four patients were menstruating normally as of the last examination.

Conclusions

The two point pull-up method enabled us to reduce intraoperative blood loss without increasing other complications during abdominal radical hysterectomy or abdominal radical trachelectomy.     

Laparoscopic radical trachelectomy or parametrectomy and pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma: report of six cases

The aim of this study was to investigate the feasibility and safety of laparoscopic radical parametrectomy and pelvic and para-aortic lymphadenectomy after previous supracervical or extrafascial hysterectomy. This is a prospective study of six patients with vaginal or cervical stump carcinoma after previous supracervical or extrafascial hysterectomy. The technique of radical parametrectomy with pelvic and para-aortic lymphadenectomy as used for open surgical cases for years was performed laparoscopically. The average operating time was 180 min, the estimated average blood loss was 220 mL, and the duration of hospitalization was 11.8 days. There was no intraoperative or postoperative complication. Laparoscopic radical parametrectomy with pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma can be successfully and safely accomplished.     

A comparison of laparascopic-assisted radical vaginal hysterectomy and radical abdominal hysterectomy in the treatment of cervical cancer

OBJECTIVES: The aim of this study was to compare peri-operative morbidity and recurrence-free survival of early-stage cervical cancer patients treated by laparoscopic-assisted radical vaginal hysterectomy (LARVH) with time-matched radical abdominal hysterectomy (RAH) controls at our center. METHODS: Since July 1984, all patients with FIGO stage IA/IB cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Since November 1996, one surgeon at our center has performed LARVH on all surgically appropriate patients. Non-parametric tests were used. Differences between medians were compared using Wilcoxon Rank Sum test. Statistical analysis used the Kaplan-Meier method to calculate disease-free survival. Differences between survival curves were compared with the log rank test. Statistical significance was defined as P < 0.05. RESULTS: Between November 1996 and December 2003, 71 and 205 patients have undergone LARVH and RAH, respectively, for FIGO stage IA/IB carcinoma of the cervix. Both groups were similar with respect to age and Quetelet index. There were no differences in tumor size, histology, grade, depth of invasion, lymph node metastases, or surgical margins. All laparoscopic procedures were completed successfully with no conversions to laparotomy. Intra-operative morbidity characteristics analyzed (LARVH vs. RAH) were blood loss 300 ml vs. 500 ml (P < 0.001), operative time 3.5 h vs. 2.5 h (P < 0.001), and intra-operative complications 13% vs. 4% (P < 0.03). Intra-operative complications in the LARVH group included: cystotomy (7), ureteric injury (1), and bowel injury (1). There was no difference in transfusion rates. There was no difference between post-operative infectious and non-infectious complications (LARVH vs. RAH), 9% vs. 5% and 5% vs. 2%, respectively. The median time to normal urine residual was 10 days vs. 5 days (P < 0.001), and the median length of hospital stay was 1 day vs. 5 days (P < 0.001). Twenty-two percent of patients received post-operative radiotherapy for high-risk features in both groups. After a median follow-up of 17 and 21 months, there have been 4 recurrences in the LARVH group and 13 in the RAH (P = NS). The overall 2-year recurrence-free survival was 94% and 94% in the LARVH and RAH groups, respectively (P = NS). CONCLUSION: Our data demonstrate that early cervical cancer can be treated successfully with LARVH with similar efficacy and recurrence rates to RAH. The major benefits are less intra-operative blood loss and shorter hospital stay. It is a safe procedure with low overall morbidity and complication rates. However, at present, LARVH is associated with an increase in intra-operative complications, and patients may have an increased time to return to normal bladder function.