Neoadjuvant chemotherapy followed by fertility sparing surgery in cervical cancers size 2–4 cm; emerging data and future perspectives

• Published in: Gynecologic oncology 2021-09, Vol.162 (3), p.809-815
• Main Authors: Gwacham, Nnamdi I., McKenzie, Nathalie D., Fitzgerald, Evan R., Ahmad, Sarfraz, Holloway, Robert W.
• Format: Article
• Language: English
• Subjects: Cervical cancer; Female; Fertility preservation; Fertility Preservation - methods; Fertility sparing surgery; Humans; Medical Oncology - methods; Neoadjuvant chemotherapy; Neoadjuvant Therapy - methods; Oncologic outcomes; Pregnancy; Recurrence; Tumor 2–4 cm; Uterine Cervical Neoplasms - drug therapy; Uterine Cervical Neoplasms - pathology; Uterine Cervical Neoplasms - surgery
• ISSN: 0090-8258; 1095-6859
• DOI: 10.1016/j.ygyno.2021.06.006

Approach to the management of early stage cervical cancers with tumor size >2 cm in women who desire fertility preservation has been fraught with controversy. Fertility sparing surgery for FIGO 2018 stage IB cancers has been validated most for tumors ≤2 cm. In this review, our objective was to evaluate the oncologic and obstetric outcomes for women that underwent neoadjuvant chemotherapy (NACT) before fertility sparing surgery for tumors 2–4 cm. We performed a systematic literature review and searched PubMed, Google Scholar, Cochrane Reviews and UpToDate (from January 2000 to February 2021) using the terms: cervical cancer, fertility preservation, trachelectomy, radical trachelectomy, neoadjuvant chemotherapy, cervical cancer treatment, stage IB1 or IB2 cervical cancer, and cervical cancer size 2–4 cm. We included manuscripts with information on patients with tumor sizes 2–4 cm, lymph node status, follow-up, obstetric and oncologic outcome. We excluded review articles or articles without all pertinent patient information. Eighteen articles were identified including 249 patients. For final analysis, 114 met inclusion criteria. All included patients had FIGO 2018 stage IB2 cervical cancer, underwent neoadjuvant chemotherapy and subsequent fertility sparing surgery. Vaginal radical trachelectomy, cold knife conization, abdominal radical trachelectomy, laparoscopic radical trachelectomy, simple vaginal trachelectomy, and cone laser were performed in 46 (40.4%), 26 (22.8%), 14 (12.3%), 13 (11.4%), 8 (7%), and 7 (6.1%) women, respectively. The most common regimen of chemotherapy was platinum-based therapy with cisplatin. The follow-up time reported in all studies ranged from 1 to 225 months. Of 64 attempted pregnancies, there were 49 (76.6%) viable deliveries which included 6 preterm births (9.4%). The recurrence rate was 6.1% and two patients (1.8%) died of disease. Fertility sparing surgery following NACT is an option for women with cervical cancers that are 2–4 cm that wish to preserve fertility without sacrificing oncologic or obstetric outcomes. Confirmation of these findings are anticipated from an ongoing international phase II clinical trial [1]. [Display omitted] •Response rate to neoadjuvant chemotherapy is 92% for cervical cancer 2–4 cm.•Recurrence rate is 6.1% after neoadjuvant chemotherapy & fertility sparing surgery.•Obstetric outcomes appear to be favorable in this subset of patients.