ORLANDO, FL—The use of radical vaginal trachelectomy, especially among younger women who wish to preserve fertility, appears to be just as save for treating adenocarcinoma of the uterine cervix as similar treatment is for squamous cell carcinoma or radical hysterectomy.
As reported in a plenary presentation here at the Annual Meeting on Women's Cancer of the Society of Gynecologic Oncology, the five-year recurrence-free survival curves virtually overlapped for women treated with either modality for either histological cancer type, said Limor Helpman, MD, a gynecologic oncologist at Lis Maternity Hospital of Tel Aviv Medical Center.
The overall survival for all the groups was excellent, she said. After five years, about 90% of the women treated in each group were free of disease recurrence. Follow-up was 43 to 62 months, depending on the group studied.
“In appropriately selected cases, radical vaginal trachelectomy is a safe alternative to radical hysterectomy for young women with adenocarcinoma of the cervix wishing to preserve fertility,” Dr. Helpman said.
“Since it was first developed in 1994, trachelectomy has emerged as a revolutionary option for fertility preservation in young women. The procedure involves the resection of the cervix while preserving the uterus. This retains the option of spontaneous conception for future pregnancy.”
The study was based on an analysis of the University of Toronto Radical Surgery for Cervical Cancer Database, which records prospectively all radical procedures performed by the gynecologic oncology team there to treat cervical cancer since 1984. Consecutive, unmatched patients with Stage 1 cervical tumors of 3 cm in maximal diameter that did not meet the definition of microinvasive tumors were considered for radical surgery.
“Patients wishing to preserve fertility, beginning in 1994, with tumors up to 2 cm were offered radical vaginal trachelectomy with laparoscopic pelvic lympha-denectomy,” she noted.
Dr. Helpman, who undertook the study as a fellow at Sunnybrook Health Sciences Center at the University of Toronto, and her colleagues compared the outcomes of patients who opted for radical vaginal trachelectomy for early-stage adenocarcinoma of the cervix with those of women who had hysterectomy for adenocarcinoma as well as women who underwent radical vagina trachelectomy for squamous cell carcinoma.
The database included 160 women who underwent radical vaginal trachelectomy and laparoscopic pelvic lymphadenectomy between March 1994 and April 2010. The researchers excluded 15 women with adenosquamous histology and five with clear cell or neuroendocrine differentiation, leaving 140 patients—66 of whom were diagnosed with squamous cell carcinoma and 74 of whom underwent trachelectomy for adenocarcinoma. These two groups were compared with each other, and the women with adenocarcinoma were compared with women with the same histology who opted for radical hysterectomy.
During the same period, 554 women underwent radical hysterectomy for cervical cancer, including 187 women diagnosed with adenocarcinoma. In the study, Dr. Helpman compared outcomes in these 187 women with the 74 women with adenocarcinoma who were treated with radical vaginal trachelectomy “to evaluate the safety of the radical vaginal trachelectomy procedure compared with the gold standard.”
The women undergoing radical vaginal trachelectomy for adenocarcinoma had a median age of 31; the median age for women seeking trachelectomy after a diagnosis of squamous cell carcinoma was 32. “Since radical vaginal trachelectomy was offered for fertility preservation, this difference was inherent to the selection process,” Dr. Helpman said. The women who were treated with hysterectomy were older, with a median age of 41.
After surgery, none of the women in the study who were treated with trachelectomy for adenocarcinoma had positive margins, compared with 2% of the women who had trachelectomy performed to treat squamous cell carcinoma and 3% of women who had a hysterectomy.
Positive pelvic nodes were found in about 3% of the women getting a trachelectomy for adenocarcinoma; positive pelvic nodes were observed in 9% of the women undergoing trachelectomy for squamous cell cancer; and positive pelvic nodes were found among women undergoing hysterectomy.
Adjuvant therapy—either radiation or chemotherapy—was prescribed for 3% of the women who had a trachelectomy for adenocarcinoma, 11% of the women who had a trachelectomy for squamous cell cancer, and 12% of the women who had hysterectomies, and the difference between the women undergoing tracheletomy for adenocarcinoma and the hysterectomy patients achieved statistical significance.
Because the study involved patients who were not matched, the researchers looked at factors that might have influenced the outcomes, such as lymphovascular space involvement, positive pelvic nodes, and adjuvant therapy requirements. However, the type of surgery did not appear to impact the results, Dr. Helpman said.
The Discussant for the study, David Kushner, MD, Division Chief and Fellowship Program Director at the University of Wisconsin School of Medicine and Public Health, said the study is particularly important due to the increasing prevalence of adenocarcinoma of the cervix as well as the unique problems in dealing with the disease, especially in determining adequate margins.
“The incidence of adenocarcinoma in this group of patients was 52%, which is much higher than that in the general population,” Dr. Kushner said. Still, he added, because Sunnybrook is a tertiary center patients may have been referred there for fertility-sparing surgery and, hence, the population of the study may have had better prognostic factors.