de-escalating the treatment of cervical cancer · de-escalating the treatment of cervical cancer...

De-Escalating the Treatment of

Cervical Cancer Ginger J. Gardner, MD

Vice Chair of Hospital Operations, Department of Surgery

Memorial Sloan Kettering Cancer Center

New York, NY

Newly Diagnosed Cervical Cancer Surgical Management

• Fertility Preservation clinical criteria and outcomes

• Radical Tumor Dissection when is less enough?

• Nodal Dissection SLN v PLND

• Women are delaying theirchildbearing to a later age

• Women ages 30-34• 28/1000 will deliver their

first child

• Women ages 35-39• 10/1000 will deliver their

first child

Mean Age of Mother by Live Birth Order

CDC National Vital Statistics Report

Delayed Childbearing

Gynecologic Cancers in Young Women

Age-specific incidence Age (years) Uterine corpus* Ovarian* Cervical*

<20 20 - 24 25 - 29 30-3435-3940-4445-49

0 0

1.2 2.9 6.4 12.9 24.0

0.7-1.4 1.6 1.9 2.9 5.4 9.2 16.6

0 1.5 6.6 11.3 12.7 14.6 14.9

http://seer.cancer.gov * Rates are per 100,000 persons

Ten Year Celebration of Radical Trachelectomy at

MSKCC June 2011

Stage IB1

Rad Abd Trach

• Confirmed invasive cervical cancer: squamous,adenoca, or adenosquamous (NOT small cell)

• FIGO IA2 to IB1

• Desire to preserve fertility

• Concern about impaired fertility – refer tospecialist

• Tumor ≤4 cm

• CXR with no metastasis; MRI as indicated

• 4-6 weeks post conization

Abu-Rustum NR, et al. Gynecol Oncol 2008;111:261 -264

Radical Abdominal Trachelectomy Which Patients are Eligible?

• MRI to Assess Canal Length

• Preop Counseling• Possible radical hysterectomy based on

intraoperative findings: lymph nodes andmargins

• Possible adjuvant radiation

• Intraoperative Margin Assessment

• Cerclage Placement

Radical Abdominal Trachelectomy MSK Algorithm


• MSKCC 2001 - 2010

• 105 Cases Attempted Radical Trachelectomy

• 77/105 (73%) Completed and No Adjuvant RT

• Median age 32 (range 6-45)

• Stage IB1=79 (75%)

• Squamous 45 (43%), Adenocarcinoma 50 (48%)

• Abdominal 49 (47%), Vaginal 51 (48%)

Radical Trachelectomy Outcomes


Radical Trachelectomy Outcomes

• Total Women Attempting Conception: 35

• Total Women Conceived a Pregnancy: 23

• 11 Spontaneously, 12 With ART

• 27 Pregnancies

• 18 Live Births: 12 (67%) at >37 weeks, 6 (33%)

32-36wks

• 4 Spontaneous Abortion

• 3 Elective Termination

• 2 Currently Pregnant Abu-Rustum NR, et al. Gynecol Oncol 2008;111:261 -264

• Requires specialized surgical experience• Risk of bladder, bowel or sexual dysfunction• Canal Stenosis• Need for Assisted Reproductive Technologies• Cervical Incompetence• Miscarriage• Painful clinical exams

…Is there another option for especially early stage disease?

Radical Trachelectomy Challenges and Risks

Cervical Conization SLN

Andikyan V…Abu-Rustum NR, Int J Gyn Cancer, 2014

• 2005 – 2012

• Selection Criteria• Stage IA1 with LVI• Stage IA2• Stage IB1 (microscopic only)

• Desires future fertility• PET/CT and Pelvic MRI performed



• Results• Median age 26yo (18-36)• 70% IAI with LVI, 30% microscopic IB1• 80% squamous, 10% adenocarcinoma, 10% clear cell

• 9 pts underwent repeat cone• Median distance to margin on 1st cone: 2.25mm ecto,

1.75mm endo• None had residual disease on 2nd cone• All nodes negative

• 17 month follow-up: no recurrences, 30% with pregnancies



• Conclusions

Liberal use of preoperative imaging and pathology review

LVI in pts with stage IA1 should not be considered a contraindication for cone/SLN (70% with LVI)

2 mm tumor clearance at all margins correlated with no residual on repeat cone

Small study…and yet, additional evaluation warranted

Ramirez P…Schmeler KM, Gyn Oncol 2014

Conservative Surgical Mgt Patient and Tumor Characteristics

Conservative Surgical Mgt

TH = Total Hysterectomy. C=6 pts had sentinel nodes alone


Procedures Completed


Conservative Surgical Mgt Obstetric Outcomes

Bogani et al, Gyn Oncol 2019

Conservative Surgical Mgt Recent Outcomes

• Stage IA2, IB1, IB2• Mean age 33• All pts underwent Cone SLN, n=32• 6/21 completed hyst due to nodes, tumor size, pt

preference

• Median FU 75 months.• 4yr PFS 94%. No recurrence in Cone SLN only patients

• The SHAPE Trial – Plante• Compares radical hysterectomy/PLND vs simple

hysterectomy/PLND SLN is Optional

• Inclusion: stage IA2 – IB1, tumor <2cm squamous or adenoca <10mm stromal invasion on LEEP/Cone <50% stromal invasion on MRI LVSI eligible

• Exclusion: high risk histology (clear cell, small cell), LN mets,NACT

• Primary Endpoints: OS, Morbidity Accrual goal: 700 pts

Prospective Trials in Low Risk Cervical Cancer

• GOG 278 – Covens• Multi-center Prospective Cohort Trial• Cone or Simple Hysterectomy, both include PLND• Inclusion: IA1 with LVSI

IA2 – IB1, tumor <2cm, <10mm stromal invasion squamous or adenoca LEEP or cone with negative margins negative metastatic survey by imaging

• Pts stratified by desire for future fertility• Endpoints: Bladder / Bowel / Sexual Dysfunction /

Lymphedema and Efficacy

Prospective Trials in Low Risk Cervical Cancer

ConCerv Trial

Sentinel Node Mapping

Cormier B et al, Gyn Oncol 2011

Conclusions • Fertility Sparing Radical Trachelectomy can be

considered for selected patients. Complexprocedure ideal for centralized surgical referral tohigh volume center. Consider intraoperativecerclage to reduce SAB and PTL rates.

• Growing data for Simple Hysterectomy or Cone (bothwith node dissection) for earliest stage disease.Awaiting results of current prospective trials.

• SLN Algorithms available for SLN in Cervical Cancerwith best detection rates for tumors <2cm.

de-escalating the treatment of cervical cancer · de-escalating the treatment of cervical cancer...

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