Radical Trachelectomy and Pelvic Lymphadenectomy with Uterine Preservation in the Treatment of Cervical Cancer
Abstract & Commentary
Synopsis: Radical trachelectomy combined with pelvic lymphadenectomy can be a feasible method of treatment for early-stage cervical cancer in women who want to preserve their fertility.
Source: Schlaerth JB, et al. Am J Obstet Gynecol. 2003;188:29-34.
Schlaerth and colleagues reported their series of 12 women with stage I cervical cancer who were scheduled to undergo radical trachelectomy and pelvic lymphadenectomy. The purpose of this pilot study was to determine whether this procedure could be a feasible method for the treatment of early-stage cervical cancer in women who want to preserve their fertility. The procedure was abandoned in 2 women because endometrial extension of the cancer was discovered at the time of surgery. Surgical margins were clear in all other women. No lymph node metastases were encountered. The proximal cervical remnant was reinforced in 10 women. Hospitalization ranged from 2 to 8 days (mean, 3.2 days). Estimated blood loss averaged 203 mL (range, 50-600 mL). Complications included 2 intraoperative cystotomies and 1 pelvic hematoma. Four pregnancies have occurred, with 2 third-trimester deliveries and 2 preterm losses at 24 and 26 weeks of gestation, respectively. The follow-up period ranged from 28 to 84 months (mean, 47.6 months). Schlaerth et al concluded that radical trachelectomy combined with pelvic lymphadenectomy could be a feasible method of treatment for early stage cervical cancer in women who want to preserve their fertility.
Comment by David M. Gershenson, MD
In 1994, Dargent first described radical vaginal trachelectomy. Subsequently, a few other groups in North America and Europe have reported their experience with this procedure. Of course, the traditional approach for treatment of early stage cervical cancer—stages IA2, IB, or IIA—involves either radical hysterectomy, radiation alone, or chemoradiation. Radical trachelectomy allows preservation of fertility. Criteria proposed by Dargent and others have included the following: 1) desire for fertility preservation; 2) stage IA2 or IB; 3) lesion size < 2 cm; 4) absence of adenocarcinoma; 5) absence of vascular/lymphatic space involvement; 6) limited endocervical involvement on colposcopic examination; and 7) no evidence of lymph node metastasis. In the present series, Schlaerth et al did not consider adenocarcinoma as a contraindication; 5 patients had an adenocarcinoma, and 1 had an adenosquamous lesion. Laparoscopic lymphadenectomy was initially performed; if lymph node metastasis is noted on frozen section examination (which was not the case in any patient in this series), then radical trachelectomy is not performed. Schlaerth et al also expanded the surgical techniques used in this series; while 6 women underwent a radical vaginal trachelectomy, 4 underwent a laparoscopically assisted vaginal trachelectomy. These were all small lesions, with the largest lesion being 2 cm in diameter. One of the unresolved issues is the importance of preoperative imaging to select patients for radical trachelectomy. As groups continue to report and update their experience with this procedure, selection criteria and intraoperative techniques will be refined. In the meantime, radical trachelectomy and pelvic lymphadenectomy is an option for young women with early cervical cancer for whom fertility preservation is an issue.
Dr. Gershenson is Professor and Chairman, Department of Gynecology, M.D. Anderson Cancer Center, Houston.