Michel Roy

The vaginal radical trachelectomy: An update of a series of 125 cases and 106 pregnancies

OBJECTIVE To review our first consecutive 125 vaginal radical trachelectomies (VRT) to assess the oncologic, fertility and obstetrical outcomes. METHODS Data from our prospective database was used to identify all VRT planned between October 1991 to March 2010 in patients with early-stage cervical cancer (stages IA, IB and IIA). Chi-square test, Fishers exact test and Student t-test were used to compare baseline characteristics and Kaplan-Meier survival curves were constructed and compared with the use of the log-rank test. RESULTS During the study period, 140 VRT were planned and 125 were performed. The median age of the patients was 31 and 75% were nulliparous. The majority of the lesions were stage IA2 (21%) or IB1 (69%) and 41% were grade 1. In terms of histology, 56% were squamous and 37% were adenocarcinomas. Vascular space invasion was present in 29% of cases, and 88.5% of the lesions measured ≤2cm. The mean follow-up was 93months (range: 4-225months). There were 6 recurrences (4.8%) and 2 deaths (1.6%) following VRT. The actuarial 5-year recurrence-free survival was 95.8% [95% CI: 0.90-0.98], whereas it was 79% [95% CI: 0.49-0.93] in the group where the VRT was abandoned (p=0.001). Higher tumor grade, LVSI and size >2cm appeared to be predictive of the risk of abandoning VRT (p=0.001, p=0.025 and p=0.03 respectively). Tumor size >2cm was statistically significantly associated with a higher risk of recurrence (p=0.001). In terms of obstetrical outcome, 58 women conceived a total of 106 pregnancies. The first and second trimester miscarriage rates were 20% and 3% respectively, and 77 (73%) of the pregnancies reached the third trimester, of which 58 (75%) delivered at term. Overall, 15 (13.5%) patients experienced fertility problems, 40% of which were due to cervical factor. Twelve (80%) were able to conceive, the majority with assisted reproductive technologies. CONCLUSION VRT is an oncologically safe procedure in well-selected patients with early-stage disease. Lesion size >2cm appears to be associated with a higher risk of recurrence and a higher risk of abandoning the planned VRT. Fertility and obstetrical outcomes post VRT are excellent.

Long-term outcome of a randomized study comparing three techniques of conization: cold knife, laser, and LEEP

OBJECTIVE To evaluate the long-term recurrence rates and complication of different techniques of cervical ablation. METHODS A randomized trial of three techniques of conization (cold knife, laser, and loop electrosurgical excisional procedure (LEEP)) for cervical intraepithelial neoplasia (CIN) in which 110 patients had been recruited. RESULTS Eighty-six patients were followed-up for more than 3 years. Of these 28 had been treated with the cold knife, 29 with LEEP and 29 by laser. Five recurrences were observed, one in the cold knife group, two in the LEEP group and two in the laser group (P=NS). The only observed complication was cervical stenosis: zero cases in the laser group, one case in the LEEP group and four cases in the cold knife group (laser versus cold knife: P=0.03; LEEP versus cold knife: P=0.06). Fifty pregnancies were observed in 39 patients. First and second trimester outcomes of pregnancy were without complications. One patient treated with the LEEP presented with a premature rupture of membranes and premature labor at 36 weeks. A total of nine cesarean sections were performed with two cases for cervical dystocia. CONCLUSION There is no major difference in obstetrical outcome between the three techniques.

An analysis of “long-term” follow-up results in patients with cervical intraepithelial neoplasia treated by cryotherapy

Two thousand eight hundred thirty-nine patients who had been treated by cryotherapy for cervical intraepithelial neoplasia (CIN) in nine different institutions were followed longitudinally after three negative Papanicolaou smears to ascertain the risk of recurrence. The cumulative risk of developing CIN after successful cryotherapeutic management of CIN was 0.41% at year 5, 0.44% at year 10, and 0.44% at year 14. There was no significant difference in risk between patients originally treated for CIN 1, CIN 2, or CIN 3.

Diagnosis and management of cervical cancer

Cervical cancer is the second most common cancer in women worldwide, with more than half a million new cases diagnosed in 2005.1 The disease disproportionately affects the poorest regions—more than 80% of cases are found in developing nations, mainly in Latin America, sub-Saharan Africa, and the Indian subcontinent.1 Cervical cancer is an important cause of early loss of life as it affects relatively young women. Important advances have taken place in the diagnosis and treatment of this cancer in recent years. Surgery or chemoradiotherapy can cure 80-95% of women with early stage disease (stages I and II) and 60% with stage III disease (table⇓).2 3 4 5 View this table: International Federation of Gynaecology and Obstetrics (FIGO) staging classification (FIGO 1995, Montreal): cervical carcinoma #### Summary points We searched the literature to identify all relevant articles published from 1966 to March 2007 (PubMed and Cochrane database) using a combination of the terms “cervical cancer”, “diagnosis”, and “management”. Variables of interest were cervical cancer, surgery, chemotherapy, radiotherapy, chemoradiotherapy, complications of treatment, recurrence, and follow-up. Much of the clinical management discussed in this review was based on meta-analyses, systematic reviews, and phase III randomised controlled trials (RCTs). Infection with high risk types of human papillomavirus is the main cause of cervical cancer.6 This has obvious implications for primary prevention (vaccination) and secondary …

Value of sentinel node mapping in cancer of the cervix

OBJECTIVES To compare the relative value of two methods of detection for the sentinel lymphatic nodes (SLNs): colorimetric with Isosulfan blue (ISB) and radio-isotopic with Technetium-99 (Tc99), and to evaluate the concept of the SLN mapping applied to cervical cancer. METHODS From October 2000 to December 2006, radical surgery was planned in 211 patients who presented early-stage cancer of the cervix. Both ISB and Tc99 were used to detect the SLNs. In all cases, we proceeded with laparoscopy for the identification and removal of the SLNs, followed by a complete pelvic lymphadenectomy with or without para-aortic node sampling. The SLNs were sent for frozen section (1 level) and were ultra-staged (6 levels) for final pathology. Detection rate, sensitivity and negative predictive value (NPV) were calculated. RESULTS Among the 211 patients, ISB (n=152) identified at least 1 SLN in 92.8% of the cases. With Tc99 (n=166), the detection rate of SLN increased to 96.9%. When both techniques were used together (n=107), Tc99 was significantly better than ISB by 7.8% (p=0.0094) and at least 1 SLN (hot and/or blue) was found in 99.1% of the cases. In 16.7% of patients, a SLN was located in aberrant sites, including 3.8% in the para-aortic area. Thirty-three out of the 211 patients (15.6%) had lymph node metastases. When considering only the 181 patients with bilateral SLNs identified, the NPV of SLN is 100% after ultra staging on final pathology and 94.2% on frozen section (FS). CONCLUSION Sentinel node mapping is feasible using laparoscopy. The radio-isotopic technique adds significantly to the rate of detection. The main benefits of SLN mapping in cervical cancer are the detection of micro-metastases on ultra staging which might be missed on routine pathological evaluation, and identification of aberrant drainage sites. However, the current frozen section techniques lack sensitivity to identify very small metastases and need refinement. SLN mapping should become the standard of care in the modern management of cervical cancer and complete pelvic lymphadenectomy could be avoided when bilateral SLNs are detected in patients with lesions less than 2 cm.

New approaches in the surgical management of early stage cervical cancer.

Quality of life has become a very important issue in deciding the extent of surgical procedures for patients affected with a variety of cancers. In recent years, more attention has been given to preserving organ function, cosmesis, and now reproductive function. As cancer treatment has improved survival in several neoplasias, cancer survivors are becoming more interested in preserving their fertility potential.We focus here on new surgical advances in the management of early stage cervical cancer, with emphasis on the radical trachelectomy technique to preserve fertility potential and the Saling procedure to prevent premature labor. We also discuss the issue of the sentinel node localization.

Vaginal radical trachelectomy in the treatment of cervical cancer: the role of frozen section.

Summary:Vaginal radical trachelectomy (VRT) is a new, alternative surgical procedure to radical hysterectomy for early stage invasive cervical carcinoma in women who desire to preserve fertility. The specimen includes the cervix, parametria, and the vaginal cuff. This study was designed to determine the indications and the best method for evaluating the resection margins of VRT specimens intraoperatively by frozen-section examination. We reviewed 61 VRT specimens planned between October 1991 and January 2002 in our center. A complementary radical hysterectomy is recommended when the tumor extends to within <5 mm of the margin. Of 61 patients, 56 were eligible (5 excluded; 53 VRT and 3 VRT followed by hysterectomy). Of 56 cases, 17 had no macroscopic or microscopic residual tumor. Of 27 cases with a nonspecific macroscopic lesion, more than one-half had no residual microscopic tumor, and the others had minimally (<1 mm) invasive residual carcinoma. In the remaining two cases with a macroscopic tumor, a longitudinal rather than a transverse frozen section was preferred, because it allowed the evaluation of the distance between the tumor and the endocervical margin. We recommend a frozen section, using a longitudinal section, only in those VRT specimens with a grossly visible lesion.

Simple vaginal trachelectomy in early-stage low-risk cervical cancer: a pilot study of 16 cases and review of the literature.

Objective This study aimed to evaluate the feasibility of simple vaginal trachelectomy and node assessment in patients with low-risk early-stage cervical cancer (<2 cm). Methods From May 2007 to November 2012, 16 women with low-risk small-volume cervical cancer underwent a simple vaginal trachelectomy preceded by laparoscopic sentinel node mapping plus or minus pelvic node dissection. Data were collected prospectively in a computerized database. Descriptive statistics and Kaplan-Meyer estimate were used for analysis. Results Patients’ median age was 30 years and 12 (75%) were nulliparous. Six had a diagnostic cone, 6 had a loop electrocautery excision procedure, 3 had cervical biopsies, and 1 had polyp excision. All patients underwent a preoperative pelvic magnetic resonance imaging. Four patients had stage IA1 with lymph vascular space invasion (LSVI), 6 IA2, and 6 IB1. Ten (62.5%) had squamous lesions, 7 had adenocarcinoma. LVSI was present in 4 cases, suspicious in 2, and absent in 10. There were 2 surgical complications: a trocar site hematoma and a vaginal laceration. The median OR time was 150 minutes (range, 120–180 minutes) and median blood loss was 50 mL (range, 50–150 mL). On final pathology, lymph nodes were negative in all patients. Thirteen (81%) patients had either no residual disease (6) or residual dysplasia only (7) in the trachelectomy specimen. Margins were negative in all cases. With a median follow-up of 27 months (range, 1–65 months), there have been no recurrences. The recurrence-free survival at 24 months is 100%. Eight patients have conceived: 3 were term deliveries and 4 are ongoing. Conclusions Simple trachelectomy and nodes seems to be a safe alternative in well-selected patients with early-stage low-risk cervical cancer. Our data will need to be confirmed in larger series.

Mucinous ovarian tumors of Mullerian-type: an analysis of 17 cases including borderline tumors and intraepithelial, microinvasive, and invasive carcinomas.

Summary: Mullerian-type mucinous tumors (MMTs) of the ovary are characterized by a papillary architecture similar to that of serous tumors and a content of endocervical-like mucinous epithelium. The latter may be admixed with other mullerian-type epithelia, including those of serous, endometrioid, and squamous types, and indifferent eosinophilic epithelial cells. We analyzed 17 MMTs, including 12 borderline tumors, 2 intraepithelial carcinomas, 2 microinvasive carcinomas, and 1 invasive carcinoma. Fourteen of 16 tumors (88%) with available staging were stage I; the remaining two cases (both borderline) were stage IIa and IIIc. Endometriosis was identified in eight cases (47%). Only two patients (12%) had bilateral tumors, a frequency of bilaterality lower than in previous studies. Five patients (31%) had conservative treatment consisting of a cystectomy or unilateral salpingo-oophorectomy. All patients had a favorable outcome, with no recurrences or disease-related deaths, regardless of the presence of high mitotic index, intraepithelial carcinoma, microinvasion, bilaterality, conservative treatment, or advanced stage. This indolent behavior of MMTs is similar to that previously reported, but additional cases of invasive carcinomas in this category are needed to better define their outcome.

Human papillomavirus and cervical lesions.

Human papillomavirus (HPV) infection has been implicated in the intraepithelial cervical changes that cause most abnormal Papanicolaou smears. To date, 14 types of HPVs have been identified. All are small, nondeveloped, icosahedral DNA viruses that share a common internal antigen. In cases of cervical HPV infection, the koilocytes and dyskeratocytes are the most frequently seen cell types. Most infections are flat aceto-white lesions. Florid condyloma acuminatum, usually detectable with the naked eye, is characterized by an irregular surface secondary to finger-like projections, in the middle of which a capillary loop comes to the surface. Spiked condyloma, not seen with the naked eye, has an irregular surface that shows asperity. 3 techniques have been used to differentiate atypical condyloma from intraepithelial neoplasia: microspectrophotometric studies, the peroxidase- antiperoxidase technique, and electronmicroscopy. There is growing evidence that papillomaviruses play an etiologic role in human genital cancer. 20-25% of dysplastic and neoplastic lesions show a coexistence of condylomas of the cervix or vulva with dysplasia or neoplasia. Epidemiologic research suggests that cervical condylomas occur at a mean age of 27.5 years, precede cervical dysplasia by 3.3 years, carcinoma in situ by 9.3 years, and invasive carcinoma by 27.4 years. The conversion of most cases of papillomas into squamous cell carcinomas requires the presence of carcinogenic initiators, 1 of which is believed to be herpes simplex virus.