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OBJECTIVE: Several controversies remain on conservative management of cervical cancer. Our aim was to develop a consensus recommendation on important and novel topics of fertility-sparing treatment of cervical cancer. METHODS: The consensus was sponsored by the Brazilian Society of Surgical Oncology (BSSO) from March 2020 to September 2020 and included a multidisciplinary team of 55 specialists. A total of 21 questions were addressed and they were assigned to specialists' groups that reviewed the literature and drafted preliminary recommendations. Further, the coordinators evaluated the recommendations that were classified by the level of evidence, and finally, they were voted by all participants. RESULTS: The questions included controversial topics on tumor assessment, surgical treatment, and surveillance in conservative management of cervical cancer. The two topics with lower agreement rates were the role of minimally invasive approach in radical trachelectomy and parametrial preservation. Additionally, only three recommendations had <90% of agreement (fertility preservation in Stage Ib2, anti-stenosis device, and uterine transposition). CONCLUSIONS: As very few clinical trials have been developed in surgery for cervical cancer, most recommendations were supported by low levels of evidence. We addressed important and novel topics in conservative management of cervical cancer and our study may contribute to literature.
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Preservação da Fertilidade , Oncologia Cirúrgica , Traquelectomia , Neoplasias do Colo do Útero , Brasil , Consenso , Feminino , Humanos , Estadiamento de Neoplasias , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/cirurgiaRESUMO
OBJECTIVE: Uterine transposition has emerged as an alternative for fertility preservation in women with pelvic malignancies that require radiotherapy. The goal of this study was to evaluate the short-term outcomes of patients undergoing uterine transposition after trachelectomy for cervical cancer or before chemoradiation for vaginal cancer. METHODS: We retrospectively evaluated patients with early stage cervical cancer after radical trachelectomy or with vaginal cancer with indication for pelvic radiation who had uterine transposition performed as fertility sparing strategy. RESULTS: Four patients with cervical cancer and one patient with vaginal cancer were included. Median age was 32 years (range 28-38). All patients had squamous cell carcinomas. All patients with cervical cancer had radical trachelectomies with sentinel lymph node dissection (SLN). Two of these patients also had pelvic lymphadenectomies. Indications for adjuvant radiotherapy was due to Sedlis criteria in two patients and to lymph node metastasis in the other two patients. The patient with stage IIB vaginal cancer was recommended primary chemoradiation. All patients underwent uterine transposition before radiotherapy. The median uterine transposition surgical time was 90 min (range 80-205) and no early complications (30 days) occurred. Average time from uterine transposition to start of radiotherapy was 16 days (10-28). After radiation, the uterus along with the ovaries and tubes were repositioned and the residual cervix sutured to the vagina. One patient declined uterine reimplantation after radiation and underwent a hysterectomy. After a median follow-up of 25 months (range 1-30), all patients were without evidence of disease. All patients with preserved uterus have normal menses after treatment. One patient has attempted to conceive with IVF techniques without success. CONCLUSIONS: Uterine transposition may be an option in selected patients with cervical and vaginal cancers who want to preserve fertility. However, further studies that address its oncological safety and obstetrical outcomes are encouraged.
Assuntos
Preservação da Fertilidade/métodos , Neoplasias do Colo do Útero/radioterapia , Útero/cirurgia , Adulto , Carcinoma de Células Escamosas , Feminino , Humanos , Duração da Cirurgia , Estudos Retrospectivos , Neoplasias do Colo do Útero/cirurgia , Útero/patologia , Neoplasias Vaginais/radioterapiaRESUMO
Objetivo: Revisar nuestra experiencia en traquelectomía radical laparoscópica en cáncer de cérvix en estado temprano. Métodos: Estudio observacional descriptivo retrospectivo de las pacientes que se sometieron a traquelectomía radical laparoscópica en el Instituto de Cancerología - Las Américas, Medellín, Colombia, entre Mayo de 2009 y Enero 2015. Resultados: Se completó satisfactoriamente el procedimiento en 13 pacientes en estadío IB1, 12 (92%) tuvieron tumores menores a 2 cm y una recibió quimioterapia neoadyuvante por un tumor de 3 cm. El tipo histológico más frecuente fue el escamoso en 7 pacientes (54%). En 5 pacientes (38%) no se evidenció enfermedad residual luego del procedimiento. El tiempo quirúrgico promedio fue de 240 min (130-340 min); la mediana de pérdida sanguínea fueron 100 ml (50-200 ml). Dos pacientes tuvieron cistotomía incidental durante la cirugía, reparadas por vía laparoscópica, una de ellas desarrollo una fístula vésico-vaginal que cerró espontáneamente. Ninguna paciente requirió transfusión sanguínea ni conversión a laparotomía. La estancia hospitalaria promedio fue de 1 día (1-3). Dos pacientes requirieron histerectomía laparoscópica. No se han reportado recurrencias ni embarazos con un seguimiento promedio 27,9 meses (8,3-64,4). Conclusión: La traquelectomía radical laparoscópica es factible y se puede realizar de manera segura en un país en desarrollo, en pacientes bien seleccionados, con cáncer de cérvix temprano que desean preservar su fertilidad. Los tiempos de seguimiento aún son cortos para conclusiones definitivas sobre el resultado obstétrico. La seguridad oncológica parece similar a la de la traquelectomía abdominal y/o vaginal.
Objective: To review our experience with laparoscopic radical trachelectomy in patients with early-stage cervical cancer. Methods: We performed a observational descriptive retrospective review of all patients who underwent a laparoscopic radical trachelectomy at the Instituto de Cancerología - Las Americas, Medellin, Colombia, between May 2009 and January 2015. Results: 13 patients completed surgery, 12 patients (92%) were diagnosed as IB1 with tumor size less than 2 cm, and one patient received neoadjuvant chemotherapy due to a 3 cm cervical tumor; histology was squamous cell carcinoma in 7 patients (54%). Five patients (38%) showed no residual disease. The mean surgical time was 240 min (130-340 min); the estimated blood loss was 100 ml (50-200 ml). Two patients had a cystotomy during surgery; one of them developed a vesicovaginal fistula that healed spontaneously. No transfusions were given. No conversions were made. Mean hospital stay 1 day (1-3 day). 2 patients required laparoscopic hysterectomy. To date, no recurrence or pregnancies has been recorded with the median follow up 27.9 months (8.3-64.4 month). Conclusion: Laparoscopic radical trachelectomy is feasible and can be performed safely in a developing country in well-selected patients with early cervical cancer who wish to preserve their fertility. Follow up times are still too short to drive definitive conclusions on obstetric results. The oncological safety appears similar to that of the abdominal trachelectomy and/or vaginal.
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BACKGROUND: Radical hysterectomy is the standard treatment for patients with early-stage cervical cancer. However, for women who wish to preserve fertility, radical trachelectomy is a safe and viable option. OBJECTIVE: To present the first case of laparoscopic radical trachelectomy performed in the National Cancer Institute, and published in Mexico. CLINICAL CASE: Patient, 34 years old, gravid 1, caesarean 1, stage IB1 cervical cancer, squamous, wishing to preserve fertility. She underwent a laparoscopic radical trachelectomy and bilateral dissection of the pelvic lymph nodes. Operation time was 330minutes, and the estimated blood loss was 100ml. There were no intraoperative or postoperative complications. The final pathology reported a tumour of 15mm with infiltration of 7mm, surgical margins without injury, and pelvic nodes without tumour. After a 12 month follow-up, the patient is having regular periods, but has not yet tried to get pregnant. No evidence of recurrence. CONCLUSIONS: Laparoscopic radical trachelectomy and bilateral pelvic lymphadenectomy is a safe alternative in young patients who wish to preserve fertility with early stage cervical cancer.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Colo do Útero/cirurgia , Preservação da Fertilidade/métodos , Laparoscopia/métodos , Neoplasias do Colo do Útero/cirurgia , Vagina/cirurgia , Adulto , Perda Sanguínea Cirúrgica , Carcinoma de Células Escamosas/diagnóstico por imagem , Feminino , Humanos , Excisão de Linfonodo , Imageamento por Ressonância Magnética , Resultado do Tratamento , Neoplasias do Colo do Útero/diagnóstico por imagemRESUMO
La incidencia de cáncer cervical ha aumentado en mujeres jóvenes, en quienes se requiere prestar atención a la preservación de la fertilidad. Se presenta dos casos de pacientes con cáncer temprano de cuello uterino, en estadios iniciales IA2 e IB1 sin metástasis en ganglios pélvicos, y se analiza nuestra experiencia en la aplicación de la técnica quirúrgica de traquelectomía radical abdominal, de manera de preservar la fertilidad.
The incidence of cervical cancer has increased in young women in whom it is important to preserve fertility. Two cases of patients with early cervical cancer stages IA2 e IB1 and no pelvic lymph nodes metastasis are presented, and experience with abdominal radical trachelectomy in order to preserve fertility is analized.
RESUMO
OBJECTIVE: Radical trachelectomy is a standard treatment for selected patients with early-stage cervical cancer. Outcomes are well established for vaginal radical trachelectomy (VRT), but not for abdominal radical trachelectomy (ART). METHODS: We searched MEDLINE, EMBASE, and CINAHL (October 1997 through October 2012) using the terms: uterine cervix neoplasms, cervical cancer, abdominal radical trachelectomy, vaginal radical trachelectomy, fertility sparing, and fertility preservation. We included original articles, case series, and case reports. Excluded were review articles, articles with duplicate patient information, and articles not in English. RESULTS: We identified 485 patients. Ages ranged from 6 to 44 years. The most common stage was IB1 (331/464; 71%), and the most common histologic subtype was squamous cell carcinoma (330/470; 70%). Operative times ranged from 110 to 586 min. Blood loss ranged from 50 to 5568 mL. Three intraoperative complications were reported. Forty-seven patients (10%) had conversion to radical hysterectomy. One hundred fifty-five patients (35%) had a postoperative complication. The most frequent postoperative complication was cervical stenosis (n=42; 9.5%). The median follow-up time was 31.6 months (range, 1-124). Sixteen patients (3.8%) had disease recurrence. Two patients (0.4%) died of disease. A total of 413 patients (85%) were able to maintain their fertility. A total of 113 patients (38%) attempted to get pregnant, and 67 of them (59.3%) were able to conceive. CONCLUSION: ART is a safe treatment option in patients with early-stage cervical cancer interested in preserving fertility.
Assuntos
Carcinoma de Células Escamosas/cirurgia , Procedimentos Cirúrgicos em Ginecologia , Recidiva Local de Neoplasia , Neoplasias do Colo do Útero/cirurgia , Abdome/cirurgia , Carcinoma de Células Escamosas/patologia , Feminino , Preservação da Fertilidade , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Gravidez , Taxa de Gravidez , Neoplasias do Colo do Útero/patologiaRESUMO
El cáncer de cérvix es la causa más común de muerte por cáncer ginecológico en el mundo. Debido al incremento del diagnóstico de esta enfermedad en estadios tempranos en mujeres en edad fértil, hacemos énfasis en los nuevos conceptos de preservación de la fertilidad y tratamiento quirúrgico mínimamente invasivo. El cono frío de cérvix con o sin linfadenectomía pélvica representa un esquema de tratamiento adecuado para el manejo de cáncer de cérvix en estadio IA1-2 en pacientes que desean conservar su fertilidad. Sin embargo, su potencial curativo no ha sido explorado extensamente en lo que concierne a la enfermedad en estadios IB1. En el Instituto Nacional de Enfermedades Neoplásicas (INEN), desde hace cinco años se ha iniciado el manejo individualizado de estas pacientes por la mayor demanda de pacientes jóvenes, quienes desean preservar la fertilidad, con el consentimiento informado de las pacientes y con resultados óptimos hasta la actualidad. Se presenta cuatro casos de cáncer de cérvix en estadios IA2 y IB1 con factores patológicos de riesgo bajo, en quienes se planteó cirugía conservadora para la preservación de la fertilidad. Se les realizó cono frío del cérvix y linfadenectomía pélvica bilateral laparoscópica. Los resultados demostraron que la cirugía conservadora en estadios tempranos de cáncer de cérvix de riesgo bajo es factible en mujeres jóvenes, logrando preservar su fertilidad, con las mismas tasas de curación que la cirugía radical.
Cervical cancer is the most frequent cause of death by gynecologic cancer in the world. Due to increased diagnosis of early stage disease in childbearing age women new concepts in fertility preservation and minimally invasive surgical treatment are emphasized. Cervical cold conization with or without pelvic lymphadenectomy is appropriate treatment for stage IA1-2 cervical cancer in patients who desire fertility. However curative potential has not been extensively explored concerning to IB1 stage disease. In the past five years individualized treatment of these patients has been started at Instituto Nacional de Enfermedades Neoplasicas (INEN) due to increased demand of young patients who wish to preserve fertility, with informed consent of patients and good current results. Four cases of stages IA2 y IB1 cervical cancer with low-risk pathology factors with conservative surgery for fertility preservation are presented. Cervical cold conization and bilateral laparoscopic pelvic lymphadenectomy was performed. Results demonstrated that conservative surgery in low risk early stages cervical cancer is feasible in young women, with fertility preservation and same cure rates as radical surgery.
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Introducción: la traquelectomía radical (TR) es una técnica quirúrgica utilizada en estadios precoces del cáncer de cérvix en aquellas mujeres que desean conservar la capacidad reproductiva. Los embarazos posteriores a esta técnica quirúrgica pueden desencadenar complicaciones obstétricas. El presente artículo tiene como objetivo hacer una revisión de la literatura en relación al pronóstico obstétrico de estas pacientes. Metodología: en este estudio se presenta un caso clínico. Posteriormente, se realiza una búsqueda en las bases de datos MEDLInE, vía PubMed, y Cochrane con las palabras clave cáncer de cérvix, traquelectomía radical, embarazo y complicaciones obstétricas. Resultados: se evaluó un total de 17 artículos que comprendieron revisiones, artículos de opinión y casos clínicos. Conclusión: la preservación de la fertilidad en estadios precoces del cáncer de cérvix mediante la traquelectomía radical está adquiriendo cada vez mayor aceptación a medida que se publican más casos en la literatura. Los resultados obstétricos parecen ser cada vez más favorables aunque son más numerosas las complicaciones en comparación con la población general.
Introduction: radical trachelectomy (TR) is a surgical technique which is used in the early stages of cervical cancer in females wishing to conserve their reproductive ability. Pregnancies following this surgical technique having been applied could trigger obstetric complications. This article was thus aimed at reviewing the literature related to these patients obstetric prognosis. Methodology: a clinical case is presented. A literature search was made in MEDLInE databases, via PubMed and Cochrane, using the following key words: cervical cancer, radical trachelectomy, pregnancy, obstetric complications. Results: 17 articles were evaluated, covering review articles, articles expressing opinion and clinical cases. Conclusion: preserving fertility in early stages of cervical cancer by radical trachelectomy is increasingly acquiring more acceptance as more cases are published in the literature. Obstetric results seem to be becoming more favorable even though complications are becoming more numerous compared to incidence in the general population.