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Commentary (Duska): Fertility-Preserving Options for Cervical Cancer

Commentary (Duska): Fertility-Preserving Options for Cervical Cancer

When the radical trachelectomy procedure was first presented by Dargent at the 1994 meeting of the Society of Gynecologic Oncologists,[1] it was considered innovative and experimental. Medical professionals worried that conservative surgery would be less successful than radical hysterectomy in controlling cancer. By 2006, data reported largely by Dargent and Plante and summarized in the current article have suggested that, for appropriately selected patients, the risk of cancer recurrence associated with fertility-preserving surgery is similar to that of the traditional surgical approach.

Complex Questions

When, then, does it become the "standard of care" to offer the option of this conservative procedure to women of reproductive age who are diagnosed with cervical cancer of limited extent? What volume of reported cases is required before gynecologic oncologists accept radical trachelectomy as a standard therapeutic option for appropriately selected patients with stage IB cervical cancer?

These questions are complex and multifactorial. The cancer control question is apparently not a major concern, assuming that patients are chosen carefully using criteria that have become increasingly refined. The optimal selection criteria, however, remain elusive. What methods should be employed to choose good candidates for this procedure? What potential complications need to be considered?

As the authors of the current review note, infertility and preterm delivery are two significant problems encountered after radical trachelectomy. How are these difficulties best addressed? Are there other options that we should be discussing with our patients?

 

Patient Selection

Data presented by the authors demonstrate that young women with lesions smaller than 2 cm who have no lymphovascular invasion are appropriate candidates for radical trachelectomy. It is essential to exclude disease beyond the cervix, and if we accept radical trachelectomy as a standard option, we are obliged to define a standard clinical and imaging evaluation designed to identify appropriate candidates.

Magnetic resonance imaging, a diagnostic tool mentioned by the authors, is probably the best currently available modality to identify parametrial spread and extension into the upper endocervix and myometrium—two findings that would render radical trachelectomy inappropriate. In addition, positron-emission tomography/computed tomography can be helpful in identifying spread to retroperitoneal lymph nodes, particularly in squamous lesions, and should be considered preoperatively for patients contemplating radical trachelectomy.[2]

As concerns about cancer recurrence subside, infertility and obstetric complications emerge as significant problems. Infertility rates after an abdominal approach seem similar to those found after a vaginal approach, but the data are limited.[3] In our own experience, infertility secondary to cervical factors has been a problem (unpublished data). Obstetric complications, particularly preterm delivery, should be addressed preoperatively.

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