Expert consensus: How to choose young patients with cervical cancer to preserve fertility?

 Since Dargent founded Extensive Cervical Resection (RT) in 1987, fertility-sparing surgery (FSS) for young patients with early cervical cancer has developed rapidly.
Dargent's procedure-laparoscopic assisted transvaginal extensive cervical resection ( LAVRT/VRT) is a classic, open wide cervix resection (ART), laparoscopic wide cervicectomy (LRT), robot-assisted laparoscopic wide cervicectomy (RRT) and other surgical methods of RT coexist, The new pattern supplemented by non-radical FSS such as cervical conization and simple cervical resection (ST) enables young patients with early cervical cancer to achieve the goal of fertility on the basis of curing the tumor
.

In order to promote and standardize FSS for early cervical cancer, experts discussed and formulated this consensus , which aims to guide clinical practice, with a view to reducing the failure rate of FSS surgery, improving the postoperative pregnancy rate, and increasing live births without affecting the oncology outcome.
Rate
.

The main points are as follows:

consensus

FSS surgical indications

FSS surgical indications

Because the FSS failure rate and adverse obstetric outcomes of patients with upper cervical infiltration are significantly increased, tumor diameters> 2 cm and poor response to NACT are high risk factors for postoperative recurrence.
Gastric adenocarcinoma and malignant adenoma and other non-human papilloma viruses ( HPV)-related cervical malignant tumors themselves have a very poor prognosis.
In order to ensure the safety of FSS and improve postoperative obstetric outcomes, this consensus recommends the following indications for FSS
.

In terms of patients: ①Have a strong desire to preserve reproductive organs and functions; ②At the reproductive age, ovarian function assessment has fertility potential; ③Cannot bear FSS and postoperative pregnancy, or suffer from diseases that are not suitable for pregnancy, and perinatal period Those with a high risk of maternal complications are not suitable for FSS; ④The reasons for choosing FSS, surgical methods and approaches, possible complications, postoperative tumor outcomes, postoperative pregnancy complications and their monitoring, pregnancy outcomes and other related issues are adequate Informed consent
.

Tumors: ①The tumor is confined to the cervix, the largest diameter is ≤2 cm, the depth of cervical interstitial invasion is ＜1/2, and the tumor is ≥1.
5cm from the internal cervical orifice; ②If the tumor diameter is 2 to 4 cm, ART may be considered, or 1 -3 Course of NACT, FSS is performed after evaluating tumor shrinkage to ≤2 cm; ③Neuroendocrine small cell carcinoma, gastric adenocarcinoma and malignant adenoma are not suitable for FSS; ④No metastasis to pelvic lymph nodes
.

Doctors: Have FSS refined management and quality control capabilities and programs, surgical skills and platform conditions
.

(Level of Evidence: Level ⅡA)

manage

FSS preoperative evaluation

FSS preoperative evaluation

This consensus recommends that PET/ceMRI is the best choice for preoperative tumor imaging evaluation of FSS in young patients with early cervical cancer
.

In view of the fact that this equipment is relatively small in China and the clinical application data is limited, MRI enhanced scan + PET/CT is the first choice, and MRI enhanced scan is the minimum standard program

Choice of FSS procedure

Choice of FSS procedure

The choice of FSS surgery depends primarily on the tumor stage.
When the oncological outcome is the same, attention should be paid to the pros and cons of the fertility outcome
.

Different stages of cervical cancer, cervical tumor resection and lymph node metastasis assessment methods at FSS are selected as follows: (Level of Evidence: Level ⅡA)

FSS cervical tumor resection has two methods: transvaginal and transabdominal.
The transvaginal route (conization of the cervix, ST or VRT) is preferred for stage IA, and the postoperative oncology and pregnancy outcomes are excellent; stage IB1 tumors are preferred for type B extensive uterus VRT with a comparable range of resection has better postoperative pregnancy outcomes than ART.
In low-risk cases, ST and cervical conization have a significantly lower preterm birth rate; ART, LRT or RRT, which has the same range of C-type extensive hysterectomy, is more suitable for IB2 Period of direct surgery
.

The PLND approach depends on the path of cervical tumor resection.

NACT pretreatment

NACT pretreatment

After 1-3 courses of NACT for stage IB2 cervical cancer, most tumors can shrink to less than 2 cm or even complete remission (CR), creating conditions for the implementation of FSS
.

The NACT program chooses cisplatin-based combination chemotherapy, such as paclitaxel combined with cisplatin (TP), 5-FU combined with cisplatin (FP), bleomycin combined with vincristine and cisplatin (BVP)

Stage IB1 cervical cancer usually undergoes FSS directly without NACT.
For those who are planning to choose non-radical FSS such as cervical conization or ST, it is recommended that 1-3 courses of NACT after the tumor reach or close to CR surgery
.

Type C ART can be performed directly in stage IB2.

Pathological evaluation of pelvic lymph nodes

Pathological evaluation of pelvic lymph nodes

This consensus recommendation is suitable for VRT, ST, or cervical conization and other transvaginal resection of cervical tumors, waiting for the paraffin pathological results after systemic PLND; SLN tracer biopsy can also be selected for complete removal of SLN frozen pathological examination
.

(Level of Evidence: ⅡB)

It is recommended that pathology over-staging be used as routine pathological examination of SLN
.

(Level of Evidence: ⅡB)

This consensus recommends that when the SLN biopsy on both sides of the SLN frozen pathological examination is negative for lymph node metastasis, it is recommended to use SLN pathology superstaging combined with new techniques such as cytokeratin immunohistochemistry or OSNA detection for further evaluation; unilateral or bilateral For those who have not developed SLN, it is recommended that systemic PLND be sent for paraffin pathological examination and evaluation
.

(Level of Evidence: ⅡB)

immunity

The timing of cervical cerclage

The timing of cervical cerclage

Whether or not to undergo cervical cerclage in patients with FSS depends on the length of the remaining cervix and the functional status of the cervix
.

Oncology and pregnancy outcomes are good, cervical cerclage is not necessary

Prevent infection

Uterine artery preservation

Uterine artery preservation

This consensus recommends that the uterine artery be preserved as much as possible during FSS
.
(Level of Evidence: ⅡA)

Intraoperative additional diseases and treatment

Intraoperative additional diseases and treatment

During FSS operation, diseases that may affect postoperative pregnancy should be treated together, normal anatomy should be restored, and the formation of postoperative pelvic-abdominal adhesions should be prevented
.
Endometriosis, large (≥5 cm) or uterine fibroids that affect the shape of the uterine cavity, endometrial polyps, intrauterine adhesions, uterine septum, benign ovarian tumors, ovarian crown cysts, hydrosalpinx adhesions, and Obstruction, pelvic inflammatory diseases, etc.
may affect the pregnancy and childbirth outcomes of FSS, which can be treated as an additional treatment during PLND; Wedge resection or perforation is not recommended for patients with polycystic ovary syndrome to prevent irreversible damage to the ovaries or functional decline; Malignant or low-grade tumors of the ovaries and/or fallopian tubes, endometrium, and other organs in the pelvic and abdominal cavity accidentally discovered during the operation are recommended to be treated according to the corresponding tumor diagnosis and treatment guidelines.
For such multiple primary tumors, it is recommended to terminate FSS
.
(Level of Evidence: ⅡB)

Prevention and management of perioperative complications

Prevention and management of perioperative complications

Cervical stenosis is a common complication after RT, mainly manifested as postoperative amenorrhea and uterine menstrual blood retention, which can be secondary to uterine and fallopian tube hemorrhage or empyema, pelvic infection and infertility
.
For patients with cervical canal stenosis after FSS, the proportion of assisted reproductive technology has increased significantly; cervical canal stenosis can be improved after transvaginal cervical dilation
.
(Level of Evidence: ⅡB)

Pregnancy related issues after FSS

Pregnancy related issues after FSS

If there are infertility factors, it is recommended to start assisted reproductive technology for 3 months after operation
.
If there is no infertility factor, it is recommended to give at least 6 months the chance of natural conception, during which time ovulation can be monitored and intercourse can be guided; for those who have not conceived or new infertility factors appear after 6 months,

Actively correct infertility factors or use assisted reproductive technology to assist pregnancy, including intrauterine insemination (IUI) and in vitro fertilization embryo transfer (IVF-ET)
.
(Level of Evidence: Ⅲ)

Preterm birth monitoring and management during pregnancy

Preterm birth monitoring and management during pregnancy

For successful pregnancy after FSS, as the pregnancy progresses, the residual cervix may gradually dilate and shorten.
During pregnancy, it is necessary to monitor the residual cervix length and the dilatation of the internal cervix, and monitor the changes in the level of fetal fibronectin in the cervical mucus
.
For those who have not undergone cervical cerclage, perform preventive or emergency transabdominal cervical cerclage when necessary; closely monitor infection and uterine contractions after surgery, including monitoring of local and systemic vaginal infections, local vaginal cleaning and disinfection, systemic antibiotic treatment, and suppression of uterine contractions , And fetal fibronectin combined with transvaginal ultrasound for preterm birth monitoring
.
Other pregnancy monitoring is the same as that of normal pregnant women
.
(Level of Evidence: ⅡB)

antibiotic

Options for termination of pregnancy

Options for termination of pregnancy

Cervical scars after FSS surgery are tough or cervical cerclage is difficult to dilate.
Those who are expected to be unable to survive should remove the cervical scar or remove the cerclage thread/band as appropriate to avoid cesarean fetus removal; cervical cerclage is not performed In addition, patients without cervical scars and toughness may suffer from soft birth canal laceration and hemorrhage due to rapid cervical dilation or acute labor.
In severe cases, uterine rupture and broad ligament hematoma may occur, and some patients may experience hemorrhagic shock
.
In the case of emergency delivery, severe birth injuries or infections of newborns occur from time to time.
High vigilance and prevention are required.
When necessary, preventive injection of tetanus antitoxin is required
.
For those who are expected to survive after FSS, regardless of whether the cervical cerclage or cervical scar is tough, cesarean section is recommended to terminate the pregnancy
.
(Level of Evidence: Ⅲ)

Reference materials:

Reference materials:

Xiong Guangwu,Zhang Shiqian,Guo Hongyan,Li Rong,Liu Kaijiang,Liu Qing,Ma Xiaoxin,Wang Gang,Wang Yingmei,Xiang Yang.
Consensus of Chinese experts on fertility-sparing surgery for early cervical cancer[J].
Chinese Journal of Minimally Invasive Surgery,2021,21(08 ): 673-679.

Xiong Guangwu,Zhang Shiqian,Guo Hongyan,Li Rong,Liu Kaijiang,Liu Qing,Ma Xiaoxin,Wang Gang,Wang Yingmei,Xiang Yang.
Consensus of Chinese experts on fertility-sparing surgery for early cervical cancer[J].
Chinese Journal of Minimally Invasive Surgery,2021,21(08 ):673-679.
Leave a message here