Lecture delivered at BOGSCON 2014 (Annual Conference of Bengal Obstetric and Gynaecological Society) held at ITC SOnar, Kolkata, January, 2014

1. FERTILITY PRESERVATION
IN CANCER CERVIX

2. Cervical Cancer
• Sexual dysfunction, loss of fertility*
• Reduced autonomic responses- engorgement,
lubrication and orgasm
• Significant dysparaeunia- due to vaginal shortening and
stenosis
* Bergmark K, Avall-Landqvist E, Dickman PW, Henningsohn L,
Steineck G. Vaginal changes and sexuality in women with a history
of cervical cancer. N Eng J Med 1999;340:1383-1389
• Surgical morbidity-
 rarely severe
 short-lived or at least stable
 treatable
 can preserve the ovarian function

3. Radical Trachelectomy
• Initial tendency of small Cx tx to spread laterally into the
parametria and LN, rather than verticaly into uterus/
vagina
• Theoretically possible to resect cervix, parametria and
lymphnodes- preserving uterus, adnexa and vagina
• Like partial nephrectomy/ gastrectomy/ pneumonectomy/
colectomy
• Structures removed-
 Majority of the Cx
 Part of parametria and paracolpos
 Part of uterosacral ligament
 1-2 cm of vaginal cuff
 Descending cervicovaginal branch of uterine artery is ligated
 Permanent encirclage of the cervical stump
 Pelvic lymph nodes
• Done abdominally, vaginally, laparoscopically

4. Abdominal Trachelectomy
Author N Stage
Estimated
blood loss Complications Live
Birth
Recurrence
Smith et al. 1997 1 IB
Rodiguez et al. 2001 3 IAI-IA2 417 1 abscess 1 0
Palfalvi 2003 1 IBI 1
Del Priore et al. 2004 1 IBI Pelvic, 6 mth
Ungar et al. 2005 33 IA2-IB2 6% amenorrhoea 2 0 (47 mth)
Abu-Rustum et al. 2005 2 IBI 0 0
Ungar et al. 2006 91 IA2-IB2 656 4.8% amenorrhoea 6 2.4%
Cibula et al. 2005 3 IA2-IBI 350-3500 1 ileus, 1 bladder atony
Bader et al. 2005 1 IB1 0 1
Abu-Rustum et al. 2006 5 IBI 280
positive margin- needed
completion Sx
0 0

5. Laparoscopically Assisted vaginal
trachelectomy (Dargent Procedure)
• 1987- Dargent described modification of Schauta-
Americh radical hysterectomy to preserve uterine
function*
• 1st laparoscopic complete pelvic lymph node dissection-
then removal of cervix along with proximal portion of
parametrium
* Dargent D. A new future for Schauta's operation through pre-surgical
laparoscopic retroperitoneal pelviscopy. Eur J Gynecol Oncol 1987;8:292
• Plante et al- after 2 decades- oncologic outcomes are
comparable to radical hysterectomy for similar sized
lesions**
** Plante M, Renaud MC, Harel F, et al. Vaginal radical trachelectomy: an
oncologically safe fertility-preserving surgery. An updated series of 72 cases
and review of the literature. Gynecol Oncol 2004;94:614

6. Selection Criteria
Eligibility criteria
• Roy M, Plante M. Pregnancies after radical vaginal trachelectomy for early-stage
cervical cancer. Am J Obstet Gynecol 1998;179(6):1491
1. Desire to preserve fertility
2. No clinical evidence of impaired fertility (relative C/I)
3. Lesion size ≤2.5 cm
4. FIGO stage 1A1 with LVSI, 1A2 and 1B1
5. Sq cell or adeno Ca
6. No involvement of the upper endocervical canal as determined by
colposcopy/ MRI
7. No mets to regional LN
• Can be done in women >40 years (reduced fertility) or those with
completed family
• Experience over 10 years in the Memorial Sloan-Kettering Cancer
Center- 48% of women undergoing radical hysterectomy would
have been candidate for trachelectomy*
* Sonoda Y, Abu-Rustum NR, Gemignani ML, et al. A fertility sparing alternative to
radical hysterectomy: how many patients may be eligible? Gynecol Oncol
2004;95:534-

7. * Abdominal radical trachelectomy
Oncologic Outcome
Authors Number Recurrences Deaths
Plante and Roy 100 2 (2.0%) 1 (1.0%)
Covens and
Steeed
121 7 (5.8%) 4 (3.3%)
Shepherd et al. 112 3 (2.7%) 2 (1.8%)
Hertel et al. 100 4 (4.0%) 2 (2.0%)
Dargent and
Mathever
95 4 (4.2%) 3(3.1%)
Ungar et al.* 91 2 (2.2%) 0
Total 619 22 (3.5%) 12 (1.9%)

8. Recurrences
• Unusual recurrences- Vesico-vaginal septum and bladder- needs
very meticuous surgical technique and dissection in proper plane to
prevent dissemination of Tx cells *
* Morice P, Dargent D, Haie-Meder C, Duvillard P, Castaigne D. First case of a centropelvic
recurrence after radical trachelectomy: literature review and implications for the preoperative
selection of patients. Gynecol Oncol 2004;92:1002-1005
• Recurrence in Cx itself- 2 cases
1. Bali- 7 yrs follow up (Recurrence or new primary-?)
2. Bader- 6 mnth FU- detected by Pap smear
• 2 recurrences after Abd trachelectomy- both having bulky Cx (3.8
cm, 5 cm respectively) **
• Role of abd trachelectomy in bulky Cx ?
** Ungar L, Plafalvi L, Smith JR, et al. Update on and long term follow up of 91 abdominal radical
trachelectomies. Gynecol Oncol 2006;101:S20(abst).
• Alternative- Neo-adjuvant chemotherapy to reduce the size of the
lesions- then radical trachelectomy
• Experience in 3 cases- all had complete response to chemo and
none had residual ds- still experimental
• Plante M, Lau S, Brydon L, et al. Neoadjuvant chemotherapy followed by vaginal radical
trachelectomy in bulky stage 1B1 cervical cancer: case report. Gynecol Oncol 2006;101:367

9. Follow up
• Shepherd JH, Mould T, Oram DH. Radical trachelectomy in the early stage carcinoma of the
cervix: outcome as judged by recurrence and fertility rates. BJOG 2001;108(8):882
• Every 3-4 months for 1st 2-3 years
• Then every 6 months for next 2 years
• Then every year
• Colposcopy, cytology and RV examination
• Colposcopy and cytology- frequently unsatisfactory because SCJ is
not often visualized and cytology often meets only squamous cells
• Atypical glandular cells from lower uterine segment is often picked
up by cyto- false +ve results
• Singh et al- 200 smears- most unsatisfactory, 2% atypical gladular
cells (suspicious), only 2 cases true recurrence- abnormality long
before clinical features*
* Singh N, Titmuss E, Aleong JC, et al. A review of post-trachelectomy isthmic and vaginal smear
cytology. Cytopathology 2004;15:97
• Shepherd- use of endoCx cytobrush for cytology and MRI 6, 12, 24
mth
• Needs expert radiologists to interprete MRI**
** Sahdev A, Jones J, Shepherd JH, et al. MR imaging appearances of the female
pelvis after trachelectomy. Radiographics 2005;25:41

10. Risk of recurrence
• Size ≥2 cm*
• LVSI*
• Adeno Ca**
*Plante M, Renaud M-C, Francois H, Roy M, Vaginal radical trachelectomy:
an oncologic safe fertility preserving surgery. An updated series of 72 cases
and review of the literature. Gynecol Oncol 2004;94:614-623
**Hertel H, Kohler C, Hillemanns P, et al. Radical vaginal trachelectomy
(RVT) combined with laparoscopic pelvic lymphadenectomy: prospective
multicenter study of 100 patients with early cervical cancer. Gynecol Oncol
2006:103;506-511

11. Obstetric outcomes
Author Pregnancy
1st
trimester
loss
Therapeutic
abortions
2nd
trimester
loss
3rd
trimester
delivery
Delivery
<32 wks
Delivery
>32 wks
Plante and
Roy
59 10 (16%) 3 (4%) 2 (5%) 44 (75%) 3 (7%) 41 (93%)
Dargent
and
Mathevet
56 11 (18%) 3 (5%) 8 (14%) 34 (61%) 5 (15%) 29 (85%)
Shepherd
et al.
52 15 (29%) 2 (4%) 7 (13%) 28 (54%) 7 (25%) 21 (75%)
covens
and
Bernardini
45 8 (16%) 0 3 (7%) 34 (77%) 6 (18%) 28 (82%)
Hertel et
al.
14 1 (7%) 2 (14%) 0 11 (78%) 3 (27%) 8 (73%)
Ungar et
al.
10 4 (40%) 0 0 6 (60%) 1 (17%) 5 (83%)
Total 236
49
(20%)
10 (4%)
20
(8%)
157
(66%)
25
(15%)
132
(85%)

12. Obstetric Outcomes (Contd.)
• 1st trimester loss- not higher than that in general
population
• 2nd trimester loss- significantly higher
• Prematurity <32 wk- 15%
• Prematurity <28 wk (↑ morbidity) - <10%
• Majority deliver at term
• Prematurity rate particularly higher after multiple
pregnancy in post-trachelectomy- needs special
consideration before IVF-ET
• Birth weight- Not significantly different as vasculat flow to
uterine artery is preserved (Klemm et al. 2005)
• Abdominal trachelectomy- Obst outcome similar but
chance of ligating uterine arteries higher- risk of IUGR

13. Eitiology of pregnancy loss
• Mechanical - uterus enlarges→ short Cx
cannot offer much support to LUS→ Cx
more likely to dilate prematurely
• Infective- main eitiology →short Cx cannot
form effective protective mucus plug
between vagina and the membranes→
subclinical chorioamnionitis → PPROM
and preterm labour

14. Obstetric Management
• Consultation with specialist in fetal-maternal medicine
• Prophylactic antibiotics and steroid to accelerate fetal
lung maturity- unclear but strongly recommended by
Shepherd*
* Shepherd JH, Mould T, Oram DH. radical trachelectomy in early
stage carcinoma of the cervix: outcome as judjed by recurrence and
fertility rates. Br J Obstet Gynaecol 2001;108:882-885
• Needs USG assessment of neo-cervix (length, diameter,
funneling) regularly**
** Petignat P, Stan C, Megevand E, Dergent D. Pregnancy after
trachelectomy: a high risk condition of preterm delivery. Report of a
case and review of the literature. Gynecol Oncol 2004;94:575-577
• Delivery should be planned at 38-39 weeks by elective
CS due to permanent encerclage

15. Decision for trachelectomy
• Many women, even after choosing such
Sx, decide not to attempt pregnancy
• Uncertain long-term survival results
• There are considerable challenges to
overcome
• Needs pre-op counseling
• In case of recurrence- total radical Sx/ RT

16. Conisation
• 1A1- LEEP, Cold knife/ Laseconisation
• Lymphatic spread extremely low (<1%)- no need
of lymphadenectomy
• Entire cone should be blocked- to prepare
adequate number of sections
• Needs careful colposcopic exam of vagina- as
most recurrences occur from this area
• 5-year survival with optimal care >95%*
* Gadducci A, Sartori E, Maggino T et al. The clinical outcome of
patients with stage 1a1 and 1a2 squamous cell carcinoma of the
uterine cervix: a Cooperation Task Force (CTF) study. cancer J
2003;24:513-516

17. • Cone biopsy- Both diagnostic and Risk of residual disease *
therapeutic
• No LVSI, both endocervical
margins and curettage -ve for
Ca/ dysplasia
• Roman LD, Felix JC, Muderspach LI, et al. Risk of residual invasive disease in women with
microinvasive squamous cancer in a conisation specimen. Obstet Gynecol. 1997;90:759
• Hopkins MP. Adenocarcinoma in situ of the cervix: the margins must be clear. Gynecol Oncol.
2000;79:4-5
Conisation (Contd.)
Sq Cell Ca Adeno Ca
Both endocx
curette and
margin -ve
4% 3%
Only
endocx
margin +ve
22%
7%
Both +ve 33%

18. Management of Stage IA2
• May be individualized using non-FIGO
information to stratify the patients as per H/P
features
 LVSI (presence/ Absence)
 Degree of differentiation
 Type of Tx (Adeno-/ Squamous Ca)
 Tx volume (higher risk at upper limit of 1A2)
• Low risk- like 1A1
• High risk- conisation + LN dissection
• Radical trachelectomy + LN dissection

19. Ovarian Transposition
• Transposing ovaries out of the planned RT field- if RT is
required
• 1st described ovarian transposition to keep the ovaries
outside the radiation field*
• No case of iatrogenic menopause in that series (4 cases)
* Lemevel A, Bourdin S, Harousseau J, et al. Ovarian transposition by laparoscopy
before radiotherapy in the treatment of Hodgkin's disease. cancer 1998;83:1420
• Bisharah and Tulandi- recommends transection of the
ovarian lig and transposition of the ovaries without
affecting fallopian tubes- positioning ovaries antero-
laterally at the level of ASIS**
** Bisharah M, Tulandi T. Laparoscopic preservation of ovarian function: an underused
procedure. Am J Obstet Gynecol 2003;188:367
• Ovarian reserve may be tested- ovarian volume, AFC,
AMH, Inhibin B

20. Results
• Normal ovarian function seen in <50% cases*
* Fenny DD, Moore DH, Look KY, et al. The fate of the ovaries after radical hysterectomy and ovarian transposition.
Gynaecol Oncol. 1995;56:3
* Anderson B, LaPolla J, Turner D, et al. Ovarian transposition in cervical cancer. Gynecol Oncol. 1993;49:206
• Risk of ovarian mets- 0.5% (sq cell Ca) and 1.7%
(adenoca)- thus incurs a small risk**
** Sutton GP, Bundy BN, Delgado G, et al. Ovarian metastasis in stage IB carcinoma of the cervix: a
Gynecologic Oncology Group (GOG) study. Am J Obstet Gynecol.1992;166:50
• In a series of 37 consecutive cases- clear cell adenoCa
of vagina and Cx, ovarian dysgerminoma and sarcoma
• Pregnancy rates in women trying for conception- 15%
(4/27) for clear cell Ca of vagina/ Cx, 80% (8/10) in
ovarian Tx ***
***Morice P, Thiam-Ba R, Castaige D, et al. Fertility results after ovarian transposition for
pelvic malignancies treated by external irradiation and brachytherapy. Hum Reprod
1998;13:660

21. Alternatives
• Oocyte retrieval
• IVF and cryopreservation (ART procedure)
• Cryopreservation of unfertilized oocytes- under research- low fertility
rates
• Autologous orthotoptic/ heterotopic transplantation after
cryopreservation- can restore fertility
• Ovarian tissue can tolerate ischaemia for at least 3 hours
• Success depends on post-grafting ischaemia time after effective
revascularization techniques
• Ethics Committee of ASRM- the physician should inform
the cancer survivors of the alternatives before initiation
of therapy*
* American Society for Reproductive Medicine. Fertility preservtion and reproduction in
cancer patients. Fertil Steril 2005;83(6):1622