ABSTRACT
OBJECTIVE: There is significant debate between up-front radical trachelectomy versus neo-adjuvant chemotherapy before fertility-sparing surgery in patients with tumors ≥2 cm. The aim of this study was to report on the oncological and obstetrical outcome of neo-adjuvant chemotherapy followed by fertility-sparing surgery, in patients diagnosed with cervical cancer ≥2 cm. METHODS: This was a retrospective review of patients diagnosed with cervical cancer measuring ≥2 cm to ≤6 cm, who were scheduled to undergo neo-adjuvant chemotherapy before fertility-sparing surgery, at six institutions from four Latin American countries between February 2009 and February 2019. Data collected included: age, International Federation of Gynecology and Obstetrics (FIGO) 2009 stage, histology, tumor size, pre-treatment imaging work-up, chemotherapy agents and number of cycles, toxicity, clinical and imaging response rate, type of fertility-sparing surgery, pathology results, timing of lymphadenectomy, follow-up time, and obstetrical and oncological outcomes. RESULTS: A total of 25 patients were included, with a median age of 27 years (range 20-37): 17 patients had stage IB1, 7 had stage IB2 cervical cancer, and 1 patient had stage IIA1 (FIGO 2009); 23 patients had squamous cell carcinoma and 2 patients had adenocarcinoma. The median number of chemotherapy cycles was 3 (range 3-6) and no toxicity grade 3-4 was reported. Lymphadenectomy was performed before chemotherapy in 6 (24%) patients. After neo-adjuvant chemotherapy 20 patients were scheduled for radical trachelectomy (11 abdominal and 9 laparoscopic) and 5 patients for conization. After surgery, no residual disease was found in 11 patients (44%). Fertility was preserved in 23 patients (92%) and 10 patients became pregnant (43.5%). After a median follow-up time of 47 months (13-133), 3 patients had recurrent disease (3/23=13%), 2 were alive without disease, and 1 patient had disease at last contact. CONCLUSION: Neo-adjuvant chemotherapy followed by fertility-sparing surgery is feasible in well selected patients with cervical tumors ≥2 cm. Future studies should focus on the timing of lymphadenectomy and type of cervical surgery.
Subject(s)
Conization/methods , Fertility Preservation/methods , Lymph Node Excision/methods , Uterine Cervical Neoplasms/surgery , Adult , Female , Humans , Neoadjuvant Therapy , Neoplasm Recurrence, Local , Neoplasm Staging , Pregnancy , Pregnancy Rate , Retrospective Studies , Uterine Cervical Neoplasms/drug therapyABSTRACT
Objetivo: Analizar las características de las lesiones preneoplásicas del tracto genital inferior (TGI) y los factores asociados a su recidiva. Material y métodos: Se estudió a 376 mujeres tratadas de algún tipo de neoplasia intraepitelial del TGI, en la década de los 90. Las lesiones se agruparon en cervicales y vulvares, y estas en lesiones de alto (CIN II-III o VIN) y de bajo grado (CIN I o atipia vulvar por virus del papiloma humano [AV-VPH]). El tratamiento de las CIN se realizó con asa diatérmica y para las lesiones vulvares fue la resección con bisturí frío y/o láser CO2.ResultadosLa edad media de las mujeres fue 32 años. La multicentricidad fue identificada en el 57% de las CIN y en el 87% de las lesiones vulvares. Un 10% de las mujeres en ambos grupos presentó algún tipo de inmunosupresión. Se identificó VPH de riesgo alto en el 25% de los casos. Con un seguimiento medio de 21 meses, la recidiva global de la CIN fue del 17% y la acumulada a 5 años del 47%. En las lesiones vulvares fue del 15 y el 54%, respectivamente. En ambos grupos lesionales la recidiva apareció en los primeros 3 años en más del 90% de los casos y se asoció a la inmunosupresión y el genotipo viral de riesgo alto, aunque el único factor de riesgo independiente en el análisis multivariante fue la inmunosupresión. Ninguna paciente progresó a cáncer invasor. Conclusiones: La inmunosupresión es el factor riesgo predictivo más importante de recurrencia. Las conductas orientadas a estimular la inmunidad podrían ser eficaces en prevención de la recurrencia de la enfermedad por el VPH (AU)
Objective: To analyze the characteristics of preneoplastic lesions of the lower genital tract (LGT) and the factors associated with their recurrence. Material and methods: A total of 376 women treated for some type of intraepithelial neoplasm of the LGT between 1990 and 1999 were studied. The lesions were classified into cervical intraepithelial neoplasms (CIN) and vulvar intraepithelial neoplasms (VIN) and were further classified into high-grade lesions (CIN 2-3 or VIN) and low-grade lesions (CIN 1 or human papillomavirus vulvar atypia [HPV-VA]). Treatment of cervical lesions consisted of CO2 laser and / or loop electrosurgical excision while that of vulvar lesions consisted of cold-knife local excision and / or CO2 laser. Results: The mean age of women was 32 years. Multicentric disease was found in 57% of CIN lesions and in 87% of vulvar lesions. Ten percent of women in both groups had some type of immunosuppression. High-risk HPV was identified in 25% of patients. With a mean follow-up of 21 months, the overall CIN recurrence was 17% and accumulated recurrence rate at 5 years was 47%. In vulvar lesions, these values were 15% and 54%, respectively. In both groups, more than 90% of recurrences occurred in the first 3 years, and relapse was associated with immunosuppression and high-risk viral genotype. In multivariate analysis, the only independent risk factor was immunosuppression. None of the lesions progressed to invasive cancer. Conclusions: The most important risk factor predictive of recurrence is immunosuppression. Measures to stimulate immunity could be effective in preventing HPV-related disease (AU)
