LOS ANGELES -- Two approaches to fertility-preserving surgery yielded results suggesting that younger women with cervical cancer face tradeoffs involving fertility versus disease control, Chinese investigators reported.
Almost four times as many women conceived after vaginal trachelectomy, resulting in twice as many live births compared with abdominal trachelectomy, reported Shen Keng, MD, and colleagues, at the Society of Gynecologic Oncology meeting.
On the other hand, no patients had recurrence of cervical cancer after abdominal trachelectomy, whereas vaginal procedures were associated with a recurrence rate of 26%. The risk of recurrence after vaginal trachelectomy was most pronounced in women who had tumors larger than 2 cm, according to Keng of Peking Union Medical College Hospital in Beijing.
"Using standardized techniques, vaginal or abdominal radical trachelectomy provides similar surgical and pathologic outcomes," Keng said. "Patients treated by abdominal radical trachelectomy obtained better oncologic results, but their fertility outcomes were not as good compared with vaginal radical trachelectomy."
"Tumor size less than 2 cm should be emphasized as an indication for radical trachelectomy for improving the outcome of fertility and prognosis," Keng added.
Increased emphasis on fertility preservation has effected a shift from radical surgery for gynecologic malignancies to more conservative techniques that reduce morbidity and improve the odds that a woman will remain fertile after surgery. At the same time, disease control has remained a necessity, regardless of the surgical approach.
About 15% of all cervical cancers arise in women younger than 40, and the proportion increases to 45% surgically treated stage IB cancers. The disease epidemiology, combined with a trend toward delayed childbearing, has made fertility preservation a priority for a growing number of women.
"These women are candidates for fertility preservation if they are identified as having a low risk of recurrence and a low risk of lymph-node involvement," Keng said.
Since its introduction in the mid-1990s, radical trachelectomy has evolved into an effective fertility-preserving agent that has acceptable oncologic outcomes for younger patients with early-stage cervical cancer.
As adoption of radical trachelectomy increased, two surgical approaches emerged: abdominal pelvic lymphadenectomy and abdominal trachelectomy versus laparoscopic pelvic lymphadenectomy and transvaginal radical trachelectomy.
Comparative outcomes of the two approaches had not been examined in detail. Toward that end, investigators at 10 centers in China established a prospective database for patients undergoing radical trachelectomy by either type of surgery.
Patients enrolled in the study were ages 18 to 40 and had FIGO stage IA1 to IB2 cervical cancer, lesions <4 cm, no involvement of the upper endocervix, no regional lymph node metastasis, a strong desire to preserve fertility, and no evidence of impaired fertility.
Thus far, investigators have enrolled 160 patients, 150 of whom had complete surgical and pathologic data. Data on oncologic outcomes were available for 126 patients followed for a minimum of 6 months, and information on pregnancy outcomes was available for 77 patients who attempted to conceive after surgery.
The 150 patients comprised 77 women who underwent vaginal radical trachelectomy and 73 who had abdominal trachelectomy. A third of patients had no evidence of disease after surgery, a third had residual disease <2 cm, and a third had residual disease ≥2 cm.
The two surgical groups did not differ significantly with respect to mean operating time, mean blood loss, or complication rates. Pathology findings, including distribution of high-risk features, also were similar between groups.
Of the 126 patients followed for at least 6 months, 71 underwent vaginal trachelectomy and 55 had abdominal trachelectomy. The vaginal group had a longer mean follow-up (34.4 versus 2o.6 months, P=0.000), and more patients in the vaginal group had been followed for at least 24 months (67.6% versus 40.0%, P=0.004).
Seven of 126 patients (5.6%) had recurrences, all in the vaginal trachelectomy group (9.8% of the group). Two recurrences involved women who had residual tumor size <2 cm and the remaining five involved women who had residual tumor ≥2 cm (P=0.040). Two patients died of cervical cancer, both in the vaginal trachelectomy group (1.6% of all patients, 2.8% of the vaginal trachelectomy group).
With respect to fertility outcomes, 77 of 126 women attempted to conceive after surgery, 17 women had a total of 20 pregnancies, and 12 women had 13 live births. Keng reported that 43 (60.6%) women in the vaginal trachelectomy group attempted to conceive, as did 34 (61.8%) of the abdominal trachelectomy group.
Pregnancy rates were 32.6% (14 of 43 women, 17 pregnancies) after vaginal trachelectomy versus 8.8% (three of 34 women) of patients who had abdominal procedures (P=0.027). Subsequently, nine women (20.9%) had 10 live births after vaginal trachelectomy compared with three (8.8%) in the abdominal trachelectomy group.
Women who had tumors >2 cm had a significantly higher rate of residual invasive cancer: 45 of 48 (93.8%) versus 78 of 102 (76.7%, P=0.019). Larger tumors also were associated with lower pregnancy rates (12.5% versus 26.4%, NS) and a trend toward fewer live births (12.5% versus 17.%, NS).
The study was supported by the National Science and Technology Infrastructure Program of China.
Keng and colleagues reported no conflicts of interest.
- Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner