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Radical Trachelectomy: A Fertility-Sparing Option for Invasive Cervical CancerBy Virginia M. Mohlere
A diagnosis of invasive cervical cancer used to mean the end of a woman’s fertility. But for the past 13 years, doctors all over the world have been working to change this. For some women with small, localized invasive cervical cancers, there is now hope of pregnancy after treatment. Each year, about 11,000 new cases of invasive cervical cancer are diagnosed in the United States, and about 3,500 women die of the disease. Most women with invasive cervical cancer undergo a radical hysterectomy and salpingo-oophorectomy. Depending on the stage of the cancer, women might also receive chemotherapy or radiation therapy. However, 43% of invasive cervical cancer diagnoses are in women aged 45 years or younger—many of whom still wish to have children. Obviously, the standard treatment doesn’t preserve this option. Enter radical trachelectomy. This fertility-sparing surgery was pioneered in France by Dr. Daniel Dargent, who published information on the first procedure in 1995. The procedure itself is tricky and difficult to master: the surgeon removes the cervix, parametrium, surrounding lymph nodes, and upper 2 cm of the vagina. The uterus is then attached to the remaining vagina. A cerclage is placed where the cervix used to be to allow the patient to carry a pregnancy. The surgery can be performed transabdominally or transvaginally. Pedro Ramirez, M.D., an associate professor in M. D. Anderson’s Department of Gynecologic Oncology, learned the radical trachelectomy procedure from Dr. Dargent and then brought the technique here in 2005.
Key to the success of radical trachelectomy is patient selection. “We’re very selective about who undergoes this procedure. It’s been shown that there is a higher risk of recurrence or need for postoperative radiation therapy if women don’t meet the specified criteria,” Dr. Ramirez said. The patients best suited for the procedure are those with squamous carcinomas or adenocarcinomas, lesions smaller than 2 cm, and no evidence of lymph node involvement. Dr. Ramirez noted that it is also critical that potential candidates be evaluated before surgery with magnetic resonance imaging to rule out any spread of the cancer. The durations of the hospital stays and recovery periods for radical trachelectomy and radical hysterectomy are similar. Rates of surgical complications are also similar. Complications specific to trachelectomy include cervical stenosis, vaginal discharge, or dysmenorrhea. Reduced fertility is also a complication; however, Dr. Ramirez said, “Reduced fertility is superior to complete loss of fertility.” Many oncologists initially expressed skepticism about radical trachelectomy because the potential risk of recurrence was not known when the procedure was developed. However, there are now 13 years’ worth of follow-up data on the nearly 550 patients around the world who have chosen radical trachelectomy, and rates of recurrence and death after recurrence (4% and 2%, respectively) are similar to those for the standard surgical procedure, radical hysterectomy.
Women who have undergone a radical trachelectomy must give birth via cesarean section, and they have a slightly higher risk of miscarriage than women in the general population. Of the patients reported in the literature who have been treated with radical trachelectomy, about half have tried to become pregnant. Among these, 75% have succeeded naturally, and 60% have delivered full-term infants. To date, a reported 204 babies have been born to mothers who had trachelectomies. In one pioneering instance, Dr. Ramirez performed a similar surgery—a simple trachelectomy, in which only the cervix is removed—on a patient who was already pregnant. The patient’s cervical cancer was diagnosed on a Pap smear at her first obstetric visit. Dr. Ramirez was able to remove the patient’s cervix and surrounding tissue without harming the fetus. Three years later, both mother and child are healthy, he said. Efforts are being made to expand the population of patients suitable for less invasive treatment of early-stage cervical cancer. A recent report in Canada showed the efficacy of chemotherapy for shrinking tumors to a size suitable for radical trachelectomy. Because as many as 60% of trachelectomy specimens have no residual disease—presumably because the entire tumor was removed during biopsy—tests are also under way to determine whether a large cone biopsy or a simple trachelectomy is sufficient to treat very small invasive cervical tumors. At M. D. Anderson, Dr. Ramirez is working hard to promote radical trachelectomy among suitable patients. He teaches the procedure to his colleagues and is exploring the use of robotic surgery in performing this procedure. To treat cervical cancer while maintaining a woman’s fertility is a significant breakthrough. With radical trachelectomy, Dr. Ramirez is hopeful that some women with invasive cervical cancer can have a good oncologic outcome while fulfilling their desire to have children. For more information, call Dr. Ramirez at 713-745-5498. Other articles in OncoLog, June 2008 issue:
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