Abstract & Commentary
Synopsis: Most women treated for stage IA1 cervical cancer with loop electroexcision have a normal outcome of pregnancy, if attempted.
Source: Paraskevaidis E, et al. Gynecol Oncol. 2002; 86:10-13.
Paraskevaidis and colleagues have previously reported that women with FIGO stage IA1 (microinvasive) cancer of the cervix could be treated successfully with loop electroexcision. The women on whom such treatment was performed generally wish to preserve fertility. Paraskevaidis et al now report a series of patients were so treated and who attempted pregnancy.
In the period 1990-1998, 47 women with microinvasive cervical cancer without vascular space involvement were treated with loop electroexcision. Of these, 28 women had at least one pregnancy that progressed beyond 24 weeks gestation and comprise the material for this study. In addition, Paraskevaidis et al performed "a case control study." Each cancer patient was matched to a woman who delivered on her service. Various risk factors and outcome variables were matched.
Because an ultrasound at 12-weeks gestation suggested cervical shortening in 5 cases, cervical cerclage was performed. There were no cerclages among the "controls." The mean gestational age at delivery of the cases was almost 38 weeks compared to 38½ weeks among the "controls." The only variable examined by Paraskevaidis et al that was different was a shorter duration of labor among those who had loop excision.
Comment by Kenneth L. Noller, MD
There are many aspects of this study that are unacceptable, and I would not have chosen it for review except for the fact that it demonstrates that women who have had huge loop electroexcision procedures performed (in this case for microinvasive cancer of the cervix) can still become pregnant and, most of the time, deliver at or near term. That is an important fact, though it has been reported before.
The second fact is that women with microinvasive cancer of the cervix without lymphatic or vascular invasion can be treated successfully with loop electroexcision. Paraskevaidis et al and others also have reported before that fact.
On the other hand, this is a terrible example of a "case control" study. In fact, it is almost an excellent example of how not to do a "case control study." There were no sample size calculations performed to assure sufficient power to detect a significant difference between the 2 groups. Thus, the fact that there were few observed differences in obstetrical outcomes between the cases and controls is rather meaningless. Secondly, I believe the choice of cases was totally inappropriate. It would have been much better to match based on maternal age, gravidity, past obstetrical history, and date of conception and then to compare outcomes between the 2 groups. With that type of selection the need for placement of cervical cerclage would have been (most likely) statistically significantly different.
Although not commented on by Paraskevaidis et al (who seem to be more interested in gynecology than obstetrics) the fact that 5 cerclages were placed among a group of 28 women suggest that loop electroexcision does indeed have a pronounced effect on subsequent pregnancy. In addition, though not statistically significantly different (due to the small sample size and lack of power), the cases had shorter mean duration of pregnancy, mean birth weight, precipitous labor, and more admissions of the neonate to the ICU. In general, the women with loop excision did less well than those without. Nonetheless, these women did achieve viable pregnancies, and thus loop excision is certainly a reasonable choice for those women with stage IA1 cervical cancer who wish to maintain fertility.
Dr. Noller is Professor and Chairman Department of OB/GYN Tufts University School of Massachusetts.Attention Readers
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