Fertility-preserving Surgery for Cervical Cancer  M. Roy and M. Planet Gynecologic Oncology. CHUQ-Hotel –Dieu de Quebec, Quebec, Canadá          Cervical cancer frequently affects young women still in their reproductive age. In early-stage disease with negative lymph nodes, the survival is very good ranging between 95 to 98 %. With such a good prognosis, loss of fertility becomes a prime concern for the patient confronted with the diagnosis of invasive cervical cancer. In fact, in most centers today, she is likely to offered a radical hysterectomy as the only treatment option.         Cold knife conization, largely used for the treatment of high grade intraepithelial lesions (HGSIL), is now recommended as a fertlility-preserving treatment for selected patients with FIGO stage Ia 1 squamous cell cervical cancer, where the rate of parametrium and pelvic lymph node involvement is negligeable. Data for micro invasive adenocarcinomas is still missing, but is thought to be similar. The fertility rate after conization is not affected, but the risk of spontaneous second trimester loss and prematurity are higher. This seems to be related to the amount of cervical tissue removed by conization. It has been demonstrated that the risk of second trimester abortion and preterm delivery are related to cervical length.         In patients with FIGO stages Ia2 disease, carrying a risk of node metastasis of up to 5 %, the treatment must include pelvic lymph node dissection and parametrectomy, in order to remove all the node-bearing pelvic tissue. With today’s knowledge, conization is not sufficient to accomplish this goal, since it leaves in place node bearing parametrial tissue. In 1987, Dargent designed a fertility-preserving operation that is oncologically satisfying, removing the affected part of the cervix and the parametrium, leaving the body of the uterus intact: radical vaginal trachelectomy (RVT), preceded by a laparoscopic pelvic  lymphadenectomy (LPL) . His first results were presented in 1994, confirming the possibility for the treated women to have babies without lowering the chances of cure. Cervical Conization         When therapeutic  conization for FIGO stage Ial is used, care must be taken to remove the affected specimen in a single piece, in order to facilitate histopathologic evaluation to rule out more invasive disease. Diathermy loop excision should not be a therapeutic modality for microinvasive lesions (13) . This technique is known to frequently give a fragmented specimen so the margins and the exact depth of invasion may be difficult to evaluate. The results for therapeutic conization performed by cold knife, laser or diathermy needle are comparable. Radical Vaginal Trachelectomy (RVT) with Laparoscopic Pelvic Lymphadenectomy (LPL) Indications • Patient who desires preservation of fertility, • FIGO stages Ial (+VSI), Ia2, Ibl, (squamous or adenocarcinoma) • Lesions < 2 cms in diameter, • Limited endocervical involvement. (as determined by MRI and colposcopy) Feasibility • No evidence of lymph node metastasis, (as determined by frozen section at laparoscopy), • Upper endocervical margins free of tumor, (as determined by frozen section of the trachelectomy specimen) Results         Four groups, in France (Dargent in Lyon: 82), Canada (Convens in Toronto: 58; Roy and Plante in Québec: 44) and the UK (Shepherd in London: 40), have presented their experience with this technique at the VIII Meeting of the International Gynecologic Cancer Society (IGCS), in October 2000, in Buenos Aires. The following numbers represent the collected data of the four Centers. Summary         Conservative treatment should be offered to young patients affected by early-stage invasive cervical cancer. Conization for micro-invasive cancer (FIGO Stage Ial, no VSI) and radical vaginal trachelectomy should not be considered “experimental” anymore. With the data showed above after LPL-RVT, we see that the recurrence rate is certainly not higher than after radical hysterectomy. Leaving intact the upper cervix and the uterine body does not put the patient at a higher risk of recurrence. Fertility is definitely preserved in most instances, but the risk of prematurity is increased.   Oncological Results: 224 patients                                                                Number of recurrences Parametrium                                                             3 (1.3 %) Pelvic side wall                                                  1 (0.4 %) Distant                                                                    3* (1.3 %) TOTAL                                                             7 (3.1 %)  * excluding two patients with small cell neuroendocrine tumors diagnosed only on final pathology, who both died despite agressive post operative adjuvant chemotherapy.  Obstetrical Results: 224 patients N. pregnancies                                   96(61 women) Live births                                         51(Prematurity<34 weeks:18) 1st. trimester losses                             Spontaneous abortion: 16                                                        Therapeutic abortion: 5                                                        Ectopic: 1          2nd. Trimester losses                                  12 Currently pregnant.                                     11

volver al menu