This article by Plante and Roy represents a comprehensive summary of the fertility-preserving options for cervical cancer patients. Despite a decline in the number of cervical cancer diagnoses in developed countries, the authors illustrate a problem that is becoming more common in these very same societies. As women continue to delay childbearing, more women who have yet to complete their families will be diagnosed with cervical cancerand will face the loss of fertility associated with their cancer treatment.
Recently, issues of cancer survivorship have garnered much attention. Quality of life has become a major focus of cancer care, and surgeons gradually have moved away from the radical en bloc resections once thought necessary for cancer cure. Their discoveries have shown that organ function may be preserved as comparable oncologic outcomes are maintained.Plante and Roy demonstrated how these principles have been applied to the surgical management of cervical cancer. Although much of the article highlights the available data for vaginal radical trachelectomy, it also addresses other surgical alternatives to trachelectomy that are beginning to appear in the literature.
Vaginal Radical Trachelectomy
The concept of a conservative surgical approach to managing cervical cancer was initially proposed by Aburel, a Romanian gynecologist who described an operation called the "subfundic radical hysterectomy" that was performed through an open incision. Interest in this procedure was quickly lost when patients had no success in becoming pregnant.
Dargent, the late French surgeon, may be credited with reviving this fertility-preserving concept. Dargent was the driving force behind the procedure he initially called the "radical trachelectomy." In 1987, he first performed the procedure using a vaginal approach; later, he coined the procedure "vaginal radical trachelectomy." Although the procedure was initially met with skepticism, Dargent remained committed to developing this technique to treat early cervical cancer patients without sacrificing their fertility. As more data about the procedure began to accumulate, the oncologic community began to recognize this method as a reasonable option for patients desiring fertility preservation.
To whom should this procedure be offered? Unfortunately, fertility preservation cannot be offered to everyone. Selection of the appropriate patient for organ-preserving surgery is imperative, since oncologic outcomes must not be compromised. Specific institutional criteria may vary, but, in general, patients should have tumors smaller than 2.0 to 2.5 cm. By employing such a cutoff, recurrence rates for patients undergoing radical vaginal trachelectomy may be kept in a range comparable to that of radical hysterectomy. Such a limited radical surgery may not be appropriate as tumor size increases. Dargent demonstrated that the risk of recurrence is 19% for tumors larger than 2 cm and 25% for tumors of that size that have invaded deeper than 1 cm. Thus, many specialists do not advocate the procedure for these larger lesions.The benefits of the vaginal radical trachelectomy are obvious. Well over 100 babies have been born to cervical cancer patients who otherwise might have been left infertile after treatment. Although these pregnancies have a high-risk nature, most of them will be carried to term. The authors have summarized issues regarding the follow-up and obstetric management of these trachelectomy patients. Consultation with perinatal specialists should be strongly considered in such cases.
Alternative Surgical Approaches