Abstract
Simple SummaryIn order to provide our contribution to the knowledge of women affected by IB2 cervical cancer, who wish to preserve fertility, we revised and updated the available literature in the debated issue of neoadjuvant chemotherapy prior to fertility-sparing treatment. The effectiveness of preoperative chemotherapy in tumors larger than 2 cm virtually proposes a conservative opportunity to a broader group of women, while keeping low, and hopefully absent, the risk of local and distant relapse. Available studies of neoadjuvant chemotherapy to the fertility-sparing approach have shown that a suboptimal response at surgery seems to be an independent prognostic factor in poorer survival, and, therefore, the careful selection of patients and the surgical approach after neoadjuvant chemotherapy remains crucial. Finally, we proposed an algorithm to be helpful in the decision-making process of that subgroup of patients.Nowadays, the optimal management of patients with cervical cancers measuring 2–4 cm desiring to maintain fertility is still uncertain. In this systematic review, we assessed the reliability of neoadjuvant chemotherapy (NACT) prior to fertility-sparing (FS) surgery in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB2 cervical cancer, in terms of pathologic response, oncological and obstetric outcomes. The review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data, using MEDLINE and PubMed, were searched for from 1 January 2005 up to 1 December 2020. We identified 20 articles and 114 women with IB2 disease, possible candidates for NACT prior to FS surgery. However, uterine conservation was achieved only in 76.7% of them. Patients reached optimal pathological response to NACT in 60.9% of cases and a TIP (cisplatin, ifosfamide and paclitaxel) regime was related to the best response. Suboptimal response to NACT appeared to be an independent negative prognostic factor. Up to 9.2% of patients recurred with a median 7.4-months DFS, and 4.6% of patients died of disease. Fifty percent of women tried to conceive after treatment and NACT prior to conization appeared to be the most promising alternative to upfront radical trachelectomy in terms of obstetric outcomes. In conclusion, NACT prior to FS surgery is an option, but the literature about this issue is still weak and FS should be carefully discussed with patients.
Highlights
Cervical cancer is the second major cause of oncological death in women aged 20–39, and almost 40% of all cervical cancer diagnosis are made in this age frame
International guidelines recommend a radical trachelectomy with pelvic node dissection as a fertility-sparing treatment for selected cases [3], but, in general, they advise fertility-sparing surgery in patients with cervical cancer ≥ 2 cm only as an experimental approach [38]
A recent study by Li et al [39] reported very promising oncological outcomes in a large series of patients with Federation of Gynecology and Obstetrics (FIGO) 2018 stage IA1 with lymph-vascular space invasion to IB2 cervical carcinoma treated with radical abdominal trachelectomy; in particular, the recurrence and death rate among the 132 patients with tumors between 2 and 4 cm was 5.3% and 3.0%, respectively
Summary
Cervical cancer is the second major cause of oncological death in women aged 20–39, and almost 40% of all cervical cancer diagnosis are made in this age frame. A valid option for women desiring to maintain fertility is an upfront radical trachelectomy, even if the data has shown that a high proportion of patients might require adjuvant treatment, due to high-risk histological factors after the upfront surgery [7]. Obstetrical outcomes in patients appear to be unsatisfactory most of the time, with a frequent need for infertility treatments and with a high rate of second trimester abortions and preterm delivery, secondary to cervical incompetence [8]. In this setting, the use of neoadjuvant chemotherapy seems to be effective in shrinking the tumor to make it more amenable to surgery, with an overall response rate reported at around 70% [9]. This review strives to provide more evidence in the feasibility, oncological and obstetric outcomes of neoadjuvant chemotherapy prior to fertility-sparing surgery in patients with a tumor diameter from 2 to 4 cm
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