Martin Hrehorcak

A less radical treatment option to the fertility-sparing radical trachelectomy in patients with stage I cervical cancer ☆

The purpose of the two pilot studies was to determine the feasibility and safety of using less-radical fertility-preserving surgery: laparoscopic lymphadenectomy with sentinel lymph node identification (SLNI) followed by a large cone or simple trachelectomy (LAP-I protocol) and the LAP-III protocol, which includes neoadjuvant chemotherapy (NAC). LAP-I: Forty women underwent laparoscopic SLNI, frozen-section analysis, and a complete pelvic lymphadenectomy as the first step of treatment. Seven days after final histopathological processing of dissected nodes, a large cone or simple vaginal trachelectomy was performed in patients with negative nodes. Nine women had a tumor larger than 20 mm, prompting the administration of three cycles of NAC before surgery. LAP-I: Six frozen sections were positive (15%). In these cases, a type III Wertheim was immediately performed. There were no false-negative SLNs. There was one central recurrence, but after chemoradiation therapy, there was no evidence of the disease 62 months post-treatment. Twenty-four of 32 women whose reproductive ability had been maintained tried to conceive. Of these 24 women, 17 became pregnant (71% pregnancy rate). Eleven mothers gave birth to 12 children (1 at 24 weeks, 1 at 34 weeks, 1 at 36 weeks, and 9 between 37 and 39 weeks). LAP-III: Nine patients were included. In 7 of these 9 women, reproductive ability was maintained, with 3 women becoming pregnant (1 full term and 2 ongoing). SLNI improves safety in fertility-sparing surgery. Large cone or simple trachelectomy combined with laparoscopic pelvic lymphadenectomy can be a feasible method that yields a high, successful pregnancy rate. NAC followed by fertility-sparing surgery is an experimental alternative treatment for larger tumors.

Less radical fertility-sparing surgery than radical trachelectomy in early cervical cancer.

The purpose of this pilot study was to determine feasibility and safety of a novel and less radical fertility-preserving surgery; laparoscopic lymphadenectomy with sentinel lymph node identification (SLNI) followed by large cone or simple trachelectomy. Obstetrical and oncologic outcomes were evaluated. Twenty-six patients (6-IA2, 20-IB1) selected on basis of favorable cervical tumor characteristics and the desire to maintain fertility underwent laparoscopic SLNI, frozen section (FS), and a complete pelvic lymphadenectomy as first step of treatment. All of nodes were submitted for microscopic evaluation (sentinel nodes for ultramicrostaging). After a 7-day interval, large cone or simple vaginal trachelectomy was performed in patients with negative nodes. The average of sentinel nodes per side was 1.50 and the average of total nodes was 28.0. Four FS were positive (15.4%). In these cases, Wertheim radical hysterectomy type III was immediately performed. We had no false-negative SLN neither on FS nor on final pathology assessment. Median follow-up was 49 months (18–84). One central recurrence (isthmic part of uterus) was observed 14 months after surgery. This patient was treated with radical chemoradiotherapy, and there was no evidence of the disease 36 months after treatment. Fifteen women planned pregnancy, 11 women became pregnant (15 pregnancies), and 7 women delivered eight children (one in 24 weeks, one in 34 weeks, one in 36 weeks, and five between 37 and 39 weeks). We conclude that lymphatic mapping and SLNI improves safety in this fertility sparing surgery. Large cone or simple trachelectomy combined with laparoscopic pelvic lymphadenectomy can be a feasible method with a high successful pregnancy rate

A prospective study of sentinel lymph node status and parametrial involvement in patients with small tumour volume cervical cancer

OBJECTIVE The purpose of prospective study is to determine incidence and distribution of pelvic lymph node (LN) involvement, sentinel lymph node (SLN) involvement and pathologic parametrial involvement (PI) in stage Ia2 and small Ib1 cervical cancer. PI is defined as positive parametrial LN or discontinuous malignant cells in parametrium. METHODS After radical abdominal hysterectomy, 158 women patients were stratified into two groups based on tumour size: In Group 1 (91 women) tumours were less than 20 mm and less than half of stromal invasion. In Group 2 (67 women) tumours were between 20 and 30 mm and infiltration was not more than 2/3 of cervical stroma. RESULTS In Group 1 positive SLN was detected in 11(12.1%) patients; of these, 3 (27.3%) had positive PI. In 80 women with negative SLN PI was not detected. In Group 2 positive SLN was detected in 14 (20.9%) patients: PI was found in four (28.6%) of these 14 patients. No PI was detected in 53 women with negative SLN. CONCLUSION No PI was observed in early cervical cancer if SLNs were negative. However, we found PI in 28.0% of women with positive SLN. Statistical analysis revealed that the results were highly significant. Based on our results, radical removal of parametrium in SLN negative patients is questionable.

High–dose density chemotherapy followed by simple trachelectomy: full‐term pregnancy

We report five patients with early-stage cervical cancer who do not fulfill criteria of fertility-sparing surgery (tumor more than 2 cm in the biggest diameter or infiltrating more than half of stroma). Five patients received three cycles of dose density neoadjuvant chemotherapy (NAC) at a 10-day interval: cisplatin plus ifosfamide in squamous cell cancer or plus doxorubicin in adenocarcinoma with good tolerance. After NAC, they underwent laparoscopic pelvic lymphadenectomy and vaginal simple trachelectomy. Two patients had no residual tumor, two had only microscopic residual disease, and one had macroscopic residual disease. Two women became pregnant 5 and 8 months after surgery, one delivered in term healthy baby and one is now in the second trimester of pregnancy without any complications. NAC followed by fertility-sparing surgery seems to be feasible treatment for women with tumor bigger than 2 cm or infiltrated more than half of the stroma.

OP21.05: Does the resistance index correlate with the size of the tumor in cervical cancer?

and 20% (n = 13) an indifferent/mixed growth pattern. None of the malignant tumors displayed the compression pattern. 35% of the 106 benign tumors (n = 37) showed the compression pattern and 59% (n = 63) an indifferent/mixed growth pattern. 5.6% of the benign tumors (n = 6) displayed a retraction pattern. Conclusions: The 3D multiplanar ultrasound analysis of breast lesions, particularly their growth pattern visible in the coronal plane, helps to distinguish between malignant and benign tumors. However, in cases with an indifferent/mixed growth pattern further investigations are necessary.

OC28.04: Transvaginal ultrasound in comparison to MRI for the evaluation of early stages of cervical cancer

Introduction: Early stages of cervical cancer are highly curable and new less radical treatment option for early stages have been recently proposed. Essential measure for accurate selection of the treatment modality is the pretreatment evaluation of the tumor extent. Currently MRI is considered to be the method of choice for estimation of tumor size and invasion of cervical stroma. The aim of our study was to determine the reliability of transvaginal ultrasound (TVUS) in comparison to MRI and to evaluate the ability of TVUS to detect correctly lesions less than 20 mm in largest diameter. Methods:73patients were evaluated in early stages of cervical cancer IA2-IB1, TVUS and MRI wasperformed separately measuring tumor volume in 3 planes. Results: Mean largest tumor diameter detected by TVUS was 21.56 mm, by MRI 26.54 mm; correlation at the level of p < 0.01 showed high statistical significance. Sensitivity of TVUS to differentiate correctly between tumors larger or smaller than 20 mm in the largest diameter was 77.1% with specificity 94.4%. Tumors in TVUS labeled as, ‘‘less than 20 mm in largest diameter’’ proved to be such in histology in 97.1% of cases in comparison to MRI that correctly labeled tumors in 74.2%. Conclusion: TVUS appears to be a method that correlates well with the results of MRI in early stages of cervical cancer. Thus selecting IB1 tumors less than 20 mm in largest diameter for less radical treatment could be reliable with TVUS.

P383: The role of transvaginal ultrasound in evaluation of cervical cancer in stage IA2-IB2

A 43-year-old woman, gravida 14, para 12, abortus 2, was referred to this hospital with a 5-month history of vaginal bleeding and lower abdominal mass. Sonographic examination revealed an enlarged uterus with a heterogeneous texture with many small anechoic areas surrounded by echogenic areas and two masses 9 cm and 6 cm in size adjacent to the fundus with the same echotexture. The sonographic appearance suggested gestational trophoblastic neoplasia, confirmed by serum βhCG of 53, 414 mIU/mL. Sonography of the abdomen showed no metastasis but an amorphous image 5 cm in length with tiny cyst was detected in the inferior vena cava at the level of the renal veins, consistent with a metastatic thrombus. The patient underwent panhysterectomy and ressection of the thrombosed right ovarian vein depicted by a CT scan and of a 6-cm segment of the inferior vena cava just beneath the renal veins. Intraoperative findings included an enlarged uterus, left anexa of 9 cm and right anexa of 6 cm, adhering firmly to each other and to the pelvic wall. Vesicles appearing to be of hydatidiform mole were found on the surface of uterus and anexae and in the lumen of the inferior vena cava. Pathology was consistent with invasive mole infiltrating the uterus and the ovaries and there was also infiltration of the wall of the removed veins. The patient was treated with multiagent chemotherapy thus obtaining healing of a pulmonary metastasis and remission of the disease. Invasive mole can and does develop in association with both partial and complete mole. In this case there was no history of partial or complete mole, but it may be presumed that as the patient came from a region with limited medical resources, her last pregnancy that ended in 16-week abortion 1.5 years previously must have been associated with an undiagnosed complete or partial mole and the lack of follow-up led to the advanced invasive mole described above.