Pre- and post-operative work-up in patients affected by early cervical cancer and eligible for fertility-sparing treatment: role of MRI with saline hydrocolpos

Imaging to assist fertility-sparing surgery

Cytological screening and human papilloma virus testing has led to diagnosis of cervical cancer in young women at an earlier stage. Defining the full extent of the disease within the cervix with imaging aids the decision on feasibility of fertility-sparing surgical options, such as extended cone biopsy or trachelectomy. High spatial resolution images with maximal contrast between tumour and surrounding background are achieved with T2-weighted and diffusion-weighted (DW) magnetic resonance imaging (MRI) obtained using an endovaginal receiver coil. Tumour size and volume demonstrated in this way correlates between observers and with histology and differences between MRI and histology estimates of normal endocervical canal length are not significant. For planning fertility-sparing surgery, this imaging technique facilitates the best oncological outcome while minimising subsequent obstetric risks. Parametrial invasion may be assessed on large field of view T2-weighted MRI. The fat content of the parametrium limits the utility of DW imaging in this context, because fat typically shows diffusion restriction. The use of contrast-enhanced MRI for assessing the parametrium does not provide additional benefits to the T2-weighted images and the need for an extrinsic contrast agent merely adds additional complexity and cost. For nodal assessment, 18fluorodeoxyglucose positron emission tomography-computerised tomography (18FDG PET-CT) remains the gold standard.

Neoadjuvant Chemotherapy Followed by Radical Surgery versus Concurrent Chemo-Radiotherapy in the Treatment of Locally Advanced Cervical Cancer: A Multicenter Retrospective Analysis

OBJECTIVES

This study aims to evaluate oncological outcomes in women affected by locally advanced cervical cancer (LACC) treated by neoadjuvant chemotherapy before radical surgery (NACT + RS) or concurrent chemo-radiotherapy (CCRT).

METHODS

This was a multicenter retrospective analysis of data related to women with LACC (FIGO stage IB2-IVA), who were treated by NACT + RS or CCRT between November 2006 and January 2018. The first endpoints were the evaluation of disease-free survival (DFS) and overall survival (OS); univariate and multivariate analyses were performed for identifying the prognostic factors independently associated with these oncological outcomes.

RESULTS

Overall, 106 women were included in the analysis; 55 of them (51.9%) underwent NACT + RS and 51 (48.1%) CCRT, respectively. Patients in the NACT + RS group had a significant better five-year DFS and five-year OS than those in the CCRT group (77.4% vs. 33.4%, p < .001 and 93.8% vs. 56.5%, p = .003). In the multivariate analyses, treatment choice (NACT + RS or CCRT) was the only independent prognostic factor for predicting both DFS (HR = 3.954; 95 CI = 1.898-8.236; p < 0.001) and OS (HR = 5.330; 95 CI = 1.563-18.178; p = 0.008).

CONCLUSIONS

This retrospective study demonstrated an improved survival outcome for patients undergoing NACT + RS compared with those undergoing CCRT. Our findings seem to support the use of NACT before RS as an effective alternative option to CCRT standard therapy.

Pelvic MRI: Is Endovaginal or Rectal Filling Needed?

Magnetic resonance imaging is the optimal modality for pelvic imaging. It is based on T2-weighted magnetic resonance (MR) sequences allowing uterine and vaginal cavity assessment as well as rectal evaluation. Anatomical depiction of these structures may benefit from distension, and conditions either developing inside the lumen of cavities or coming from the outside may then be better delineated and localized. The need for distension, either rectal or vaginal, and the way to conduct it are matters of debate, depending on indication for which the MR examination is being conducted. In this review, we discuss advantages and potential drawbacks of this technique, based on literature and our experience, in the evaluation of various gynecological and rectal diseases.

The Value of Diffusion-Weighted Imaging in Combination With Conventional Magnetic Resonance Imaging for Improving Tumor Detection for Early Cervical Carcinoma Treated With Fertility-Sparing Surgery

OBJECTIVE

This study aimed to investigate the value of diffusion-weighted imaging (DWI) in combination with conventional magnetic resonance imaging (MRI) for improving tumor detection in young patients treated with fertility-sparing surgery because of early cervical carcinoma.

METHODS

Fifty-four patients with stage Ia or Ib1 cervical carcinoma were enrolled into this study. Magnetic resonance examinations were performed for these patients using conventional MRI (including T1-weighted imaging, T2-weighted imaging, and dynamic contrast-enhanced MRI) and DWI. The apparent diffusion coefficient (ADC) values of cervical carcinoma were analyzed quantitatively and compared with that of adjacent epithelium. Sensitivity, positive predictive value, and accuracy of 2 sets of MRI sequences were calculated on the basis of histologic results, and the diagnostic ability of conventional MRI/DWI combinations was compared with that of conventional MRI.

RESULTS

The mean ADC value from cervical carcinoma (mean, 786 × 10 mm/s ± 100) was significantly lower than that from adjacent epithelium (mean, 1352 × 10 mm/s ± 147) (P = 0.01). When the threshold ADC value set as 1010 × 10 mm/s, the sensitivity and specificity for differentiating cervical carcinoma from nontumor epithelium were 78.2% and 67.2%, respectively. The sensitivity and accuracy of conventional MRI for tumor detection were 76.0% and 70.4%, whereas the sensitivity and accuracy of conventional MRI/DWI combinations were 91.7% and 90.7%, respectively. Conventional MRI/DWI combinations revealed a positive predictive value of 97.8% and only 4 false-negative findings.

CONCLUSIONS

The addition of DWI to conventional MRI considerably improves the sensitivity and accuracy of tumor detection in young patients treated with fertility-sparing surgery, which supports the inclusion quantitative analysis of ADC value in routine MRI protocol before fertility-sparing surgery.

Role of Imaging in Fertility-sparing Treatment of Gynecologic Malignancies

Treatments for gynecologic cancer usually result in loss of fertility due to surgery or radical radiation therapy in the pelvis. In countries with an established screening program for cervical cancer, the majority of gynecologic malignancies occur in postmenopausal women. However, a substantial number of affected women are of childbearing age and have not completed their families. In these younger women, consideration of fertility preservation may be important. This article describes the fertility-sparing treatment options that are currently available and outlines the role of imaging in the selection of eligible patients on the basis of a review of the literature. In the setting of cervical cancer, magnetic resonance (MR) imaging is used to delineate the size, position, and stage of the tumor for selection of patients who are suitable for radical trachelectomy. In patients with solitary complex adnexal masses, diffusion- and perfusion-weighted MR imaging sequences are used to categorize the likelihood of invasive or borderline malignancy for consideration of unilateral ovarian resection, with fertility preservation when possible. In patients with endometrial cancer, MR imaging is used to rule out signs of invasive disease before hormone therapy is considered. Imaging is also used at patient follow-up to detect recurrent disease; however, evidence to support this application is limited. In conclusion, imaging is an essential tool in the care of patients with gynecologic malignancies who are considering fertility-preserving treatment options. ^©RSNA, 2016.

[Laparoscopic radical trachelectomy for preservation of fertility in early cervical cancer. A case report]

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.

Fertility-sparing surgery for early-stage cervical cancer

Nowadays cervical cancer is diagnosed in many women who still want to have children. This led to the need to provide fertility-sparing treatments. The main goal is to maintain reproductive ability without decreasing overall and recurrence-free survival. In this article, we review data on procedures for fertility preservation, namely, vaginal and abdominal trachelectomy, less invasive surgery and neoadjuvant chemotherapy. For each one, oncological and obstetrical outcomes are analyzed. Comparing to traditionally offered radical hysterectomy, the overall oncologic safety is good, with promising obstetrical outcomes.