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Schuurman TN, Schaafsma M, To KH, Verhoef VMJ, Sikorska K, Siebers AG, Wenzel HHB, Bleeker MCG, Roes EM, Zweemer RP, de Vos van Steenwijk PJ, Yigit R, Beltman JJ, Zusterzeel PLM, Lok CAR, Bekkers RLM, Mom CH, van Trommel NE. Optimising follow-up strategy based on cytology and human papillomavirus after fertility-sparing surgery for early stage cervical cancer: a nationwide, population-based, retrospective cohort study. Lancet Oncol 2023; 24:1349-1358. [PMID: 37952541 DOI: 10.1016/s1470-2045(23)00467-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND The optimal follow-up strategy to detect recurrence after fertility-sparing surgery for early stage cervical cancer is unknown. Tailored surveillance based on individual risks could contribute to improved efficiency and, subsequently, reduce costs in health care. The aim of this study was to establish the predictive value of cervical cytology and high-risk human papillomavirus (HPV) testing to detect recurrent cervical intraepithelial neoplasia grade 2 or worse (CIN2+; including recurrent cervical cancer) after fertility-sparing surgery. METHODS In this nationwide, population-based, retrospective cohort study, we used data from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Databank. All patients aged 18-40 years with cervical cancer of any histology who received fertility-sparing surgery (ie, large loop excision of the transformation zone, conisation, or trachelectomy) between Jan 1, 2000, and Dec 31, 2020, were included. Pathology data from diagnosis, treatment, and during follow-up were analysed. The primary and secondary outcomes were the cumulative incidence of recurrent CIN2+ and recurrence-free survival, overall and stratified by results for cytology and high-risk HPV. FINDINGS 1548 patients were identified, of whom 1462 met the inclusion criteria. Of these included patients, 19 568 pathology reports were available. The median age at diagnosis was 31 years (IQR 30-35). After a median follow-up of 6·1 years (IQR 3·3-10·8), recurrent CIN2+ was diagnosed in 128 patients (cumulative incidence 15·0%, 95% CI 11·5-18·2), including 52 patients (cumulative incidence 5·4%, 95% CI 3·7-7·0) with recurrent cervical cancer. The overall 10-year recurrence-free survival for CIN2+ was 89·3% (95% CI 87·4-91·3). By cytology at first follow-up visit within 12 months after fertility-sparing surgery, 10-year recurrence-free survival for CIN2+ was 92·1% (90·2-94·1) in patients with normal cytology, 84·6% (77·4-92·3) in those with low-grade cytology, and 43·1% (26·4-70·2) in those with high-grade cytology. By high-risk HPV status at first follow-up visit within 12 months after surgery, 10-year recurrence-free survival for CIN2+ was 91·1% (85·3-97·3) in patients who were negative for high-risk HPV and 73·6% (58·4-92·8) in those who were positive for high-risk HPV. Cumulative incidence of recurrent CIN2+ within 6 months after any follow-up visit (6-24 months) in patients negative for high-risk HPV with normal or low-grade cytology was 0·0-0·7% and with high-grade cytology was 0·0-33·3%. Cumulative incidence of recurrence in patients positive for high-risk HPV with normal or low-grade cytology were 0·0-15·4% and with high-grade cytology were 50·0-100·0%. None of the patients who were negative for high-risk HPV without high-grade cytology, at 6 months and 12 months, developed recurrence. INTERPRETATION Patients who are negative for high-risk HPV with normal or low-grade cytology at 6-24 months after fertility-sparing surgery, could be offered a prolonged follow-up interval of 6 months. This group comprises 80% of all patients receiving fertility-sparing surgery. An interval of 12 months seems to be safe after two consecutive negative tests for high-risk HPV with an absence of high-grade cytology, which accounts for nearly 75% of all patients who receive fertility-sparing surgery. FUNDING KWF Dutch Cancer Society.
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Affiliation(s)
- Teska N Schuurman
- Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, location Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, location Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Mirte Schaafsma
- Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, location Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, Netherlands; Department of Pathology, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, Netherlands; Department of Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Kaylee H To
- Faculty of Medicine, VU Amsterdam, Amsterdam, Netherlands
| | - Viola M J Verhoef
- Department of Obstetrics and Gynecology, Maxima Medical Center, Eindhoven, Netherlands
| | - Karolina Sikorska
- Department of Biostatistics, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Albert G Siebers
- Palga, the Dutch Nationwide Pathology Databank, Houten, Netherlands
| | - Hans H B Wenzel
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Maaike C G Bleeker
- Department of Pathology, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, Netherlands; Department of Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Eva Maria Roes
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ronald P Zweemer
- Department of Gynecologic Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Peggy J de Vos van Steenwijk
- Department of Obstetrics and Gynecology, Maastricht University Medical Center and GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Refika Yigit
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, Netherlands
| | - Jogchum J Beltman
- Department of Gynecology, Leiden University Medical Center, Leiden, Netherlands
| | - Petra L M Zusterzeel
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Christianne A R Lok
- Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, location Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ruud L M Bekkers
- Department of Obstetrics and Gynecology, Maastricht University Medical Center and GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands; Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, Netherlands
| | - Constantijne H Mom
- Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, location Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Nienke E van Trommel
- Department of Gynecologic Oncology, Center of Gynecologic Oncology Amsterdam, location Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, Netherlands.
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Ferraro A, Laibangyang A, Yazdani A, Hurwitz J, Chuang L. Recurrent cervical cancer after trachelectomy diagnosed by hysteroscopy: A case report. Gynecol Oncol Rep 2023; 45:101134. [PMID: 36683776 PMCID: PMC9853302 DOI: 10.1016/j.gore.2023.101134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 01/12/2023] Open
Abstract
Surveillance for cervical cancer recurrence after radical trachelectomy is challenging and warrants additional research to establish evidence-based screening guidelines. Papanicolaou (Pap smear) with HPV testing, physical exam, and symptom reporting remain the standard of care despite high false positive rates. In this patient with a history of early-stage cervical adenocarcinoma status post radical trachelectomy, a diagnosis of recurrence was made hysteroscopically, prompting evaluation of the utility of this technique for screening and management of patients with suspected recurrent cervical cancer after trachelectomy.
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Affiliation(s)
- Amanda Ferraro
- Department of Obstetrics, Gynecology and Reproductive Sciences of Danbury Hospital, 24 Hospital Ave, Danbury, CT 06810, United States,Corresponding author at: 24 Hospital Ave, Department of OBGYN, Danbury, CT 06810, United States.
| | - Anya Laibangyang
- Department of Obstetrics, Gynecology and Reproductive Sciences of Danbury Hospital, 24 Hospital Ave, Danbury, CT 06810, United States
| | - Ariella Yazdani
- Larner College of Medicine at the University of Vermont, 89 Beaumont Ave, Burlington, VT 0540, United States
| | - Joshua Hurwitz
- Department of Obstetrics, Gynecology and Reproductive Sciences of Danbury Hospital, 24 Hospital Ave, Danbury, CT 06810, United States,Illume Fertility, Reproductive Endocrinology and Infertility, 103 Newtown Rd #1A, Danbury, CT 06810, United States
| | - Linus Chuang
- Department of Obstetrics, Gynecology and Reproductive Sciences of Danbury Hospital, 24 Hospital Ave, Danbury, CT 06810, United States,Larner College of Medicine at the University of Vermont, 89 Beaumont Ave, Burlington, VT 0540, United States
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Toro de Méndez M, Azuaje de Inglessis AB. Importancia de la adecuación de la muestra citológica en la pesquisa de cáncer de cuello uterino. REPERTORIO DE MEDICINA Y CIRUGÍA 2022. [DOI: 10.31260/repertmedcir.01217372.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objetivo: revisión realizada para destacar la importancia de una muestra citológica óptima para la pesquisa de cáncer de cuello uterino y sus lesiones precursoras, con fines preventivos de diagnóstico y conocimiento de los lineamientos de manejo clínico vigentes, mediante una adecuada muestra. Material y metodología. se realizó una búsqueda electrónica en la base de datos PubMed utilizando los siguientes términos y combinaciones: cervical cytology, screening cervical cáncer, Bethesda system, adecuacy, false negatives, clinical follow-up. Las variables fueron la adecuación de la muestra citológica para pesquisa de cáncer de cuello uterino establecida por el sistema Bethesda y el seguimiento clínico vigente. Resultados: la evaluación de la calidad de la muestra citológica se considera como principal aporte de garantía de calidad del sistema Bethesda para el informe de los hallazgos. Existen lineamientos de manejo clínico relacionados con la adecuada muestra y el seguimiento clínico establecidos hace más de una década y que aún son vigentes. Conclusiones: una muestra citológica óptima permite detectar una mayor proporción de lesiones del cuello uterino significativas, contribuye a la efectividad clínica de la pesquisa de cáncer y establece el mejor cuidado para la paciente. Es necesario concientizar al personal involucrado sobre la importancia de obtener muestras adecuadas.
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Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: Oncological outcomes. Gynecol Oncol 2021; 163:100-104. [PMID: 34330536 DOI: 10.1016/j.ygyno.2021.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The standard procedure in cervical cancer is radical hysterectomy (RH) and pelvic lymphadenectomy (PLND). Because of the increasing age of women at childbirth, fertility becomes a major challenge. We present 20 years of experience with two-step less radical fertility-sparing surgery in women with IA1, LVSI positive, IA2 and IB1 (<2 cm, infiltration less than half of stromal invasions. MATERIALS AND METHOD Preoperative workout consisted of histopathological diagnosis and magnetic resonance imaging along with ultrasonographic volumetry. We then performed laparoscopic sentinel lymph node mapping (SLNM) with frozen section (FS) followed by PLND and "selective parametrectomy" (removal of afferent lymphatic channels from the paracervix) in case of a negative result. If verified by definitive histopathology, patients were treated by simple trachelectomy (IB1) or large cone (IA1/IA2) biopsy 1 week after primary surgery. RESULTS From 1999 to 2018, 91 women were enrolled in the study (median age 29.1 years, range 21-40). Of these 91 women, 51 (56.0%) were nulliparous. The detection rate of SLNs was 100% per patient and the specific side detection rate 96.7%. Positive lymph nodes were diagnosed in nine cases (9.8%). These women then underwent RH. Fertility was spared in 80 women but 4 recurred locally (5.0%). The mortality rate was 0.0%. The median follow-up was 149 months. CONCLUSION Less radical fertility-sparing surgery with SLNM is safe in cervical cancers <2 cm at the largest diameter and infiltrating less than half of the cervical stroma. The recurrence rate is acceptable with no mortality. Morbidity with this procedure is low. Extended and accurate follow-up is necessary and human papillomavirus - high risk (HPV-HR tests seem to be useful in such follow-up assessment.
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