Intraoperative margin assessment of the radical trachelectomy specimen

High- or Intermediate-Risk Histologic Features in Patients with Clinical Early-Stage Cervical Cancer Planned for Fertility-Sparing Surgery: A Systematic Review

BACKGROUND

Fertility-sparing surgery (FSS) is a viable option for young women with early-stage cervical cancer (ECC); however, certain risk factors may necessitate additional treatments and impact fertility. This review examines the prevalence of these risk factors and available treatment options.

METHODS

A systematic search was conducted of studies including patients with ECC (IA1 with LVSI, IA2, IB1 (FIGO 2009)) who underwent FSS.

RESULTS

Sixty-four articles, comprising a total of 4118 women planned for FSS, were included. High- or intermediate-risk histologic features were found in 638 (15.5%) women: 5.1% had positive lymph node(s), 4.1% had positive resection margins, 0.3% had parametrial involvement, 1.0% had unspecified high-risk features, and 5.1% had intermediate-risk histology (primarily based on the Sedlis criteria). Adjuvant treatment impaired fertility in all women with adjuvant hysterectomy and/or (chemo)radiation (58.7%). Adjuvant chemotherapy was given to 1351 (32.8%) patients, which may reduce fertility.

CONCLUSIONS

Fertility preservation could be achieved in most women; but high- or intermediate-risk factors necessitate more extensive surgery or radiotherapy leading to infertility. Adjuvant chemotherapy could be an alternative treatment option considering its effectiveness, safety and higher change in fertility preservation. The low incidence of parametrial involvement justifies waiving parametrectomy in tumors < 2 cm.

Endocervical Adenocarcinoma, Gross Examination, and Processing, Including Intraoperative Evaluation: Recommendations From the International Society of Gynecological Pathologists

The International Society of Gynecological Pathologists (ISGyP) Endocervical Adenocarcinoma Project aims to provide evidence-based guidance for the pathologic evaluation, classification, and reporting of endocervical adenocarcinoma. This review presents the recommendations pertaining to gross evaluation and intraoperative consultation of specimens obtained from patients in the setting of cervical cancer. The recommendations are the product of review of published peer-reviewed evidence, international guidelines and institutional grossing manuals, as well as deliberation within this working group. The discussion presented herein details the approach to the different specimen types encountered in practice: loop electrosurgical excision procedure, cone, trachelectomy, radical hysterectomy, pelvic exenteration, and lymphadenectomy specimens. Guidelines for intraoperative evaluation of trachelectomy and sentinel lymph node specimens are also addressed. Correlation with ISGyP recommendations on cancer staging, which appear as a separate review in this issue, is also included when appropriate. While conceived in the framework of endocervical adenocarcinoma, most of the discussion and recommendations can also be applied to other cervical malignancies.

Radical Trachelectomy for Early Stage Cervical Cancer

OPINION STATEMENT

In patients with early-stage cervical cancer, radical hysterectomy and pelvic lymphadenectomy is the gold standard. However, this disease commonly affects women of childbearing age; thus an option to spare fertility is ideal. This option came to fruition in the early 90s when the Dargent procedure or radical trachelectomy was first reported. The procedure has subsequently been modified as technology has improved and now may be performed via minimally invasive techniques. Additionally, with the advent of the sentinel lymph node procedure, the morbidity in this usually young patient population has continued to improve. There is a multitude of data to show that oncologic outcomes, concerning recurrence and mortality, are comparable to radical hysterectomy, as well as obstetrical outcomes are favorable. Data to support its acceptance within the gynecologic oncology community has led to radical trachelectomy being implemented into governing body guidelines and should be offered to appropriate candidates with early-stage cervical cancer who wish to preserve fertility.

Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ≥2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease.

FINDINGS

Available literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors ≥ 2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions ≥ 2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation.

CONCLUSION

Today, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.

A new method of surgical margin assuring for abdominal radical trachelectomy in frozen section

OBJECTIVES

The aim of this study was to introduce a new method of assuring surgical margins for abdominal radical trachelectomy (ART) and report our experience using the method.

METHODS

We combined transverse and perpendicular sections to assess surgical margins of specimens from RT. All surgeries from 1st August 2012 to 1st October 2013 were performed by one surgeon. The frozen section (FS) was consistently performed by a group of gynaecologic pathologists according to the detailed protocol described in this article. All cases were prepared by the same pathologist, and the slides were reviewed by two pathologists.

RESULTS

There were 53 patients treated using the new method in our institution. The patient ages ranged from 20 to 41 years old (median 32). The surgeries were performed for clinical stage IA (n = 11) with LVSI and IB (n = 42) tumours (40 squamous cell carcinoma, 11 adenocarcinoma, two adenosquamous and two others). In 20 (37.74%) cases, no residual tumour of the ART specimen on frozen section was observed in the specimens as it was cleared by the preceding loop electrical excision procedure (LEEP) or conization. The margins were initially reported as negative in 45 cases and positive in nine cases. In those nine cases, a second slice of cervix was removed and negative in six cases and positive again in two cases, the other one with positive nodes. The results of frozen sections were concordant with the final paraffin-embedded sections. There were no false negative intraoperative assessments. There were no recurrences after a median follow-up of 15.4 months (range, 6-21 months).

CONCLUSIONS

Combining transverse and perpendicular sections to assess surgical margins of specimens from RT makes the protocol simple, reliable and produces accurate results.