Pelvic cancers

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The standard surgery of cervical cancer involves hysterectomy combined with nodal staging surgery (extended lymphadenectomy or elected nodal dissection with sentinel lymph node biopsy)(1). 

According to the stage and grade, fertility-sparing surgery can be proposed to young patients with a future pregnancy wish, in order to keep the uterus and the adnexa in place while removing the cervical disease. It may involve simple or radical trachelectomy with different technical procedures (a vaginal approach with or without laparoscopic lymph node dissection combined, or an abdominal approach, meaning either laparotomy, laparoscopy or robot-assisted laparoscopy). This can be considered in the presence of an early-stage cervical cancer and a conventional histotype, and absence of extra-cervical disease and unfavorable prognostic factor (2,3). 

Prognostic factors to consider to choose the best surgical approach are tumor size, lymphovascular space involvement, and depth of stromal invasion. However, the two latter can be accurately determined after the full pathologic examination of the cervix, making the decision around fertility-spearing surgery particularly challenging in a number of cases (4). 

Neoadiuvant chemotherapy can be proposed to those patients with unfavourable prognosis factors, to allow a further surgical conservative approach. Chemotherapy usually combines platinum-based drug, paclitaxel and ifosfamide. This, especially when combined with radiotherapy, may be highly detrimental for the ovarian reserve (5). For this reason, ovarian tissue cryopreservation can be discussed before neoadjuvant treatments. However, a potential risk of ovarian metastasis needs to be considered in adenocarcinomas, especially in the presence extra-cervical disease (6). 

Radiotherapy (percutaneous or brachytherapy) with more than 45 Gy to the uterus also has to be considered, since it is associated with poor obstetric prognosis, hence making a pregnancy non-advisable (7). 

References:

  1. Cibula D, Pötter R, Planchamp F, Avall-Lundqvist E, Fischerova D, Haie Meder C, et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients With Cervical Cancer. Int J Gynecol Cancer. 2018 May;28(4):641-655.
  2. Bentivegna E, Gouy S, Maulard A, Chargari C, Leary A, Morice P. Oncological outcomes after fertility-sparing surgery for cervical cancer: a systematic review. Lancet Oncol. 2016 Jun;17(6):e240-e253. 
  3. Morice P, Maulard A, Scherier S, Sanson C, Zarokian J, Zaccarini F, et al. Oncologic results of fertility sparing surgery of cervical cancer: An updated systematic review. Gynecol Oncol. 2022 Apr;165(1):169-183. 
  4. Machida H, Iwata T, Okugawa K, Matsuo K, Saito T, Tanaka K, et al. Fertility-sparing trachelectomy for early-stage cervical cancer: A proposal of an ideal candidate. Gynecol Oncol. 2020 Feb;156(2):341-348.
  5. Schüring AN, Fehm T, Behringer K, Goeckenjan M, Wimberger P, Henes M, Henes J, Fey MF, von Wolff M. Practical recommendations for fertility preservation in women by the FertiPROTEKT network. Part I: Indications for fertility preservation. Arch Gynecol Obstet. 2018 Jan;297(1):241-255.
  6. Ronnett BM, Yemelyanova AV, Vang R, Gilks CB, Miller D, Gravitt PE, Kurman RJ. Endocervical adenocarcinomas with ovarian metastases: analysis of 29 cases with emphasis on minimally invasive cervical tumors and the ability of the metastases to simulate primary ovarian neoplasms. Am J Surg Pathol. 2008 Dec;32(12):1835-53.
  7. Teh WT, Stern C, Chander S, Hickey M. The impact of uterine radiation on subsequent fertility and pregnancy outcomes. Biomed Res Int. 2014;2014:482968.

 

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