trachelectomy Dotaz Zobrazit nápovědu
Cíl studie: Diskuse o dosavadních zkušenostech s abdominální radikální trachelektomií v léčbě časných stadií karcinomu děložního hrdla u mladých žen. Typ studie: Kazuistiky. Název a sídlo pracoviště: Gynekologicko-porodnická klinika I. LF UK a VFN, Praha. Metodika: Prezentace 4 případů abdominální radikální trachelektomie s pánevní lymfadenektomií. Diskuse s literárními zkušenostmi. Výsledky: Prezentovány jsou 3 případy laparotomické a 1 případ laparoskopické abdominální radikální trachelektomie s pánevní lymfadenektomií. Výkony byly indikovány pro karcinom děložního hrdla stadia IA2 až IB1. Peroperačně byly vyšetřeny pánevní uzliny a vzorek tkáně z kraniálního okraje děložního hrdla bez nálezu metastáz resp. infiltrace nádorem. Získáno bylo 22–43 pánevních lymfatických uzlin, ve všech případech bez metastáz. Operační čas byl 148–270 min. u laparotomických výkonů a 250 min. u laparoskopické operace. Krevní ztráta 350–2500 ml. Ani jeden případ nebyl provázen peroperační komplikací, pooperační průběh byl u jedné pacientky komplikován hypotonickým měchýřem, řešeným suprapubickou derivací moči do 30. dne, u jiné pacientky byl konzervativně řešen subileózní stav. Hojení sutury pochvy k děložnímu tělu proběhlo per primam ve všech případech. Dosavadní follow-up 1–5 měsíců je bez komplikací. Závěry: Abdominální radikální trachelektomie s pánevní lymfadenektomií je racionální alternativou v léčbě stadií IA2–IIA karcinomu děložního hrdla u žen ve fertilním věku. Výhodou abdominálního přístupu je standardní radikalita resekce parametrií a využití běžné erudice v onkogynekologické chirurgii. Nutnost laparotomie může být eliminována při využití laparoskopického přístupu.
Objective: Discussion of current experiences with abdominal radical trachelectomy in the treatment of early stages of cervical cancer in fertile women. Design: Case-reports. Setting: Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty, Charles University, Prague. Methods: Presentation of 4 cases of abdominal radical trachelectomy and pelvic lymphadenectomy. Discussion with published data. Results: Three cases of open abdominal and one case of laparoscopic abdominal radical trachelectomies together with pelvic lymphadenectomies are presented. All procedures were indicated for cervical cancer stages IA2–IB1. Frozen section of pelvic nodes and a slice of upper margin of cervix revealed no metastasis or infiltration. In total 22–43 pelvic nodes were removed, being negative in all cases. Operative time ranged between 148 and 270 min. in laparotomy and 250 min. in laparoscopy. Blood loss reached 350–3500 ml. There were no intraoperative complications, postoperatively one case of bladder atony was treated by suprapubic drainage for 30 days, one case of ileus was managed pharmacologically. Vaginal suture healed properly in all cases. No complications occurred within limited follow-up of 1–5 months. Conclusion: Abdominal radical trachelectomy with pelvic lymphadenectomy is a rational alternative in the treatment of stages IA2–IIA cervical cancer in women of fertile age. Standard radicality in parametria resection and easy incorporation into armamentarium of oncogynecological centers are main advantages of such approach. Laparotomy can be avoided using laparoscopy.
- MeSH
- dospělí MeSH
- gynekologické chirurgické výkony metody MeSH
- komplikace těhotenství patologie terapie MeSH
- laparoskopie metody MeSH
- lidé MeSH
- lymfadenektomie metody MeSH
- nádory děložního čípku chirurgie patologie terapie MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
V současné době jsme svědky zavádění nových, méně radikálních metod v léčbě časného cervikál-ního karcinomu. Radikální trachelektomie s laparoskopickou pánevní lymfadenektomií přdstavu-jí jednu z těchto možností. Tento výkon je specifický a unikátní v tom, že nejenže přistupujek chirurgické léčbě cervikálního karcinomu akceptabilním onkologickým způsobem, ale současněmůže zachovat fertilní potenciál pacientky. Ve své podstatě tedy tento výkon představuje kom-promis mezi konizací a radikální hysterektomií. V této studii detailně analyzujeme techniku radi-kální trachelektomie na základě vlastních zkušeností, které konfrontujeme s kompletnídostupnou literaturou na toto téma.Uzavíráme, že pokud je dodržen opatrný výběr pacientek, výsledky této nové operační technikyjsou srovnatelné s výsledky klasické radikální chirurgie.
In recent years a new less radical methods in the treatment of early cervical carcinoma has beenintroduced. The radical trachelectomy with laparoscopic pelvic lymphadenectomy represents oneof these options. This procedure is special in that it not only treats the cervical cancer in accept-able oncological fashion but at the same time preserves the fertility potential of the patients.Thus, this surgery represents a midway point in between conisation and radical hysterectomy.Based on our initial experience in this study the technique of radical trachelectomy is analysed indetail and at the same time the current literature on the subject is reviewed.We conclude that after careful selection of the patients this more conservative approach leads tothe same results comparable to classical radical surgery.
- MeSH
- dospělí MeSH
- fertilita MeSH
- gynekologické chirurgické výkony metody MeSH
- hysterektomie metody MeSH
- karcinom diagnóza chirurgie MeSH
- laparoskopie metody MeSH
- lidé MeSH
- nádory děložního čípku diagnóza chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- přehledy MeSH
BACKGROUND: Radical trachelectomy is considered a viable option for fertility preservation in patients with low-risk, early-stage cervical cancer. Standard approaches include laparotomy or minimally invasive surgery when performing radical trachelectomy. PRIMARY OBJECTIVE: To compare disease-free survival between patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive (laparoscopic or robotic) radical trachelectomy. STUDY HYPOTHESIS: We hypothesize that minimally invasive radical trachelectomy has similar oncologic outcomes to those of the open approach. STUDY DESIGN: This is a collaborative, multi-institutional, international, retrospective study. Patients who underwent a radical trachelectomy and lymphadenectomy between January 1, 2005 and December 31, 2017 will be included. Institutional review board approval will be required. Each institution will be provided access to a study-specific REDCap (Research Electronic Data Capture) database maintained by MD Anderson Cancer Center and will be responsible for entering patient data. INCLUSION CRITERIA: Patients with squamous, adenocarcinoma, or adenosquamous cervical cancer FIGO (2009) stages IA2 and IB1 (≤2 cm) will be included. Surgery performed by the open approach or minimally invasive approach (laparoscopy or robotics). Tumor size ≤2 cm, by physical examination, ultrasound, MRI, CT, or positron emission tomography (at least one should confirm a tumor size ≤2 cm). Centers must contribute at least 15 cases of radical trachelectomy (open, minimally invasive, or both). EXCLUSION CRITERIA: Prior neoadjuvant chemotherapy or radiotherapy to the pelvis for cervical cancer at any time, prior lymphadenectomy, or pelvic retroperitoneal surgery, pregnant patients, aborted trachelectomy (intra-operative conversion to radical hysterectomy), or vaginal approach. PRIMARY ENDPOINT: The primary endpoint is disease-free survival measured as the time from surgery until recurrence or death due to disease. To evaluate the primary objective, we will compare disease-free survival among patients with FIGO (2009) stage IA2 or IB1 (≤2cm) cervical cancer who underwent open versus minimally invasive radical trachelectomy. SAMPLE SIZE: An estimated 535 patients will be included; 256 open and 279 minimally invasive radical trachelectomy. Previous studies have shown that recurrence rates in the open group range from 3.8% to 7.6%. Assuming that the 4.5-year disease-free survival rate for patients who underwent open surgery is 95.0%, we have 80% power to detect a 0.44 HR using α level 0.10. This corresponds to an 89.0% disease-free survival rate at 4.5 years in the minimally invasive group.
- MeSH
- lidé MeSH
- miniinvazivní chirurgické výkony metody MeSH
- nádory děložního čípku patologie chirurgie MeSH
- přežití po terapii bez příznaků nemoci MeSH
- retrospektivní studie MeSH
- roboticky asistované výkony metody MeSH
- staging nádorů MeSH
- trachelektomie metody MeSH
- zachování plodnosti metody MeSH
- Check Tag
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
BACKGROUND: Minimally invasive radical trachelectomy has emerged as an alternative to open radical hysterectomy for patients with early-stage cervical cancer desiring future fertility. Recent data suggest worse oncologic outcomes after minimally invasive radical hysterectomy than after open radical hysterectomy in stage I cervical cancer. OBJECTIVE: We aimed to compare 4.5-year disease-free survival after open vs minimally invasive radical trachelectomy. STUDY DESIGN: This was a collaborative, international retrospective study (International Radical Trachelectomy Assessment Study) of patients treated during 2005-2017 at 18 centers in 12 countries. Eligible patients had squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma; had a preoperative tumor size of ≤2 cm; and underwent open or minimally invasive (robotic or laparoscopic) radical trachelectomy with nodal assessment (pelvic lymphadenectomy and/or sentinel lymph node biopsy). The exclusion criteria included neoadjuvant chemotherapy or preoperative pelvic radiotherapy, previous lymphadenectomy or pelvic retroperitoneal surgery, pregnancy, stage IA1 disease with lymphovascular space invasion, aborted trachelectomy (conversion to radical hysterectomy), or vaginal approach. Surgical approach, indication, and adjuvant therapy regimen were at the discretion of the treating institution. A total of 715 patients were entered into the study database. However, 69 patients were excluded, leaving 646 in the analysis. Endpoints were the 4.5-year disease-free survival rate (primary), 4.5-year overall survival rate (secondary), and recurrence rate (secondary). Kaplan-Meier methods were used to estimate disease-free survival and overall survival. A post hoc weighted analysis was performed, comparing the recurrence rates between surgical approaches, with open surgery being considered as standard and minimally invasive surgery as experimental. RESULTS: Of 646 patients, 358 underwent open surgery, and 288 underwent minimally invasive surgery. The median (range) patient age was 32 (20-42) years for open surgery vs 31 (18-45) years for minimally invasive surgery (P=.11). Median (range) pathologic tumor size was 15 (0-31) mm for open surgery and 12 (0.8-40) mm for minimally invasive surgery (P=.33). The rates of pelvic nodal involvement were 5.3% (19 of 358 patients) for open surgery and 4.9% (14 of 288 patients) for minimally invasive surgery (P=.81). Median (range) follow-up time was 5.5 (0.20-16.70) years for open surgery and 3.1 years (0.02-11.10) years for minimally invasive surgery (P<.001). At 4.5 years, 17 of 358 patients (4.7%) with open surgery and 18 of 288 patients (6.2%) with minimally invasive surgery had recurrence (P=.40). The 4.5-year disease-free survival rates were 94.3% (95% confidence interval, 91.6-97.0) for open surgery and 91.5% (95% confidence interval, 87.6-95.6) for minimally invasive surgery (log-rank P=.37). Post hoc propensity score analysis of recurrence risk showed no difference between surgical approaches (P=.42). At 4.5 years, there were 6 disease-related deaths (open surgery, 3; minimally invasive surgery, 3) (log-rank P=.49). The 4.5-year overall survival rates were 99.2% (95% confidence interval, 97.6-99.7) for open surgery and 99.0% (95% confidence interval, 79.0-99.8) for minimally invasive surgery. CONCLUSION: The 4.5-year disease-free survival rates did not differ between open radical trachelectomy and minimally invasive radical trachelectomy. However, recurrence rates in each group were low. Ongoing prospective studies of conservative management of early-stage cervical cancer may help guide future management.
- MeSH
- adenokarcinom mortalita chirurgie MeSH
- adenoskvamózní karcinom mortalita chirurgie MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- miniinvazivní chirurgické výkony MeSH
- mladiství MeSH
- mladý dospělý MeSH
- nádory děložního čípku mortalita chirurgie MeSH
- přežití po terapii bez příznaků nemoci MeSH
- spinocelulární karcinom mortalita chirurgie MeSH
- trachelektomie MeSH
- zachování plodnosti MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- Research Support, N.I.H., Extramural MeSH
- Geografické názvy
- Brazílie MeSH
The abdominal radical trachelectomy is one of the available fertility-sparing techniques in the treatment of early-stage cervical cancer. The procedure follows the steps of the standard radical hysterectomy and therefore does not require special training. A radical abdominal trachelectomy allows for the adjustment of radicality of the parametrial resection according to prognostic factors and is not limited by distorted cervicovaginal anatomy. The key limitation for the procedure remains the cranial extent of the tumor towards the internal cervical os. Only a limited number of successful pregnancies have been reported to date. Poor fertility outcome, however, may partially be attributed to the selection of patients, requiring more extensive procedure, for the abdominal approach. The abdominal radical trachelectomy is a technique of choice, especially in centers with limited experience with vaginal radical surgery, and in certain specific indications, such as pediatric patients, distorted vaginal anatomy, bulky exophytic tumor, or cervical cancer in the first half of pregnancy. In this article, we describe the standard technique of this procedure along with alternatives, including a nerve-sparing modification of the parametrectomy.
Cervical cancer is one of the most common cancers in women worldwide. Because it often affects women of childbearing age (19-45 years), fertility-sparing surgery is an important issue. The article reviews current viable fertility-sparing options with a special focus on trachelectomy, including vaginal radical trachelectomy, abdominal radical trachelectomy and simple trachelectomy. Neoadjuvant chemotherapy is also discussed. Finally, the decision to proceed with fertility-sparing treatment should be a patient-driven process.
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
- MeSH
- dospělí MeSH
- gynekologické chirurgické výkony metody MeSH
- lidé MeSH
- lymfadenektomie MeSH
- nádory děložního čípku chirurgie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
BACKGROUND: Abdominal radical trachelectomy (ART) is one of the fertility-sparing procedures in women with early-stage cervical cancer. In comparison with vaginal radical trachelectomy, the published results of ART are so far limited. METHODS: Enrolled were women referred for ART either by laparoscopy or laparotomy. The main inclusion criterion was stage IA2 or IB1 with a cranial extent that allows for preservation of at least 1 cm of the endocervical canal. RESULTS: A total of 24 women were referred for the procedure, but fertility could not be preserved in 7 (29%) of them. Four women underwent immediate completion of radical hysterectomy because of a positive cranial surgical margin (n = 2) or sentinel node macrometastasis (n = 2) on frozen section. We found no correlation between tumor volume and inability to preserve fertility. A positive sentinel node was identified in 4 patients (17%); there were no false-negative results. Of the 9 women (53%) who have tried to conceive so far, 6 (67%) have conceived and 5 given birth, 2 of which were premature deliveries. CONCLUSIONS: Fertility cannot be preserved because of positive cranial margins or involved lymph nodes in almost one third of patients originally referred for radical trachelectomy. The main criterion for the selection of suitable patients should be the cranial extent of the tumor. Abdominal radical trachelectomy allows for achievement of satisfactory obstetrical outcomes.
- MeSH
- adenokarcinom chirurgie patologie MeSH
- biopsie sentinelové lymfatické uzliny MeSH
- břicho chirurgie patologie MeSH
- dospělí MeSH
- fertilita MeSH
- gynekologické chirurgické výkony MeSH
- hysterektomie MeSH
- lidé MeSH
- lymfatické metastázy MeSH
- nádory děložního čípku chirurgie patologie MeSH
- následné studie MeSH
- prognóza MeSH
- spinocelulární karcinom chirurgie patologie MeSH
- staging nádorů MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- práce podpořená grantem MeSH
Objective: The purpose of this study was to determine the 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 oncological outcomes were evaluated. Material and Methods: Forty patients (3-IA1, 10-IA2, 27-IB1), selected on the basis of favourable cervical tumour characteristics and the desire to maintain fertility underwent laparoscopic SLNI, frozen section (FS) and a complete pelvic lymphadenectomy as the first step of treatment. All of the nodes were submitted for microscopic evaluation (sentinel nodes for ultramicrostaging). After a seven-day interval, large cone or simple vaginal trachelectomy was performed in patients with negative nodes. Results: Finally we saved fertility in 32 women. The average of the sentinel nodes per side was 1.50 and the average of the total nodes was 27.8. Six FS were positive (15.0%). In these cases Wertheim radical hysterectomy type III was immediately performed. There were no false negative SLN results. Median follow-up was 46 months (12–102). One central recurrence (isthmic part of the 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. One patient in follow up had HG SIL/HPV HR positive – patient decided for hysterectomy. 24 women planed pregnancy, we had 23 pregnancies in 17 women; we had 12 children (1 in 24 weeks, 1 in 34 weeks, 1 in 36 weeks and 9 between 37 to 39 weeks). Conclusions: 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. Key words: simple trachelectomy, sentinel lymph node, cervical cancer, fertility sparing surgery.
- MeSH
- biopsie sentinelové lymfatické uzliny MeSH
- fertilita MeSH
- financování organizované MeSH
- hysterektomie metody využití MeSH
- laparoskopie metody využití MeSH
- lidé MeSH
- lymfadenektomie metody využití MeSH
- nádory děložního čípku diagnóza chirurgie prevence a kontrola MeSH
- výsledky a postupy - zhodnocení (zdravotní péče) MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- abstrakty MeSH
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.
