Linus T' Chuang, MD

1
Radical Trachelectomy for Early Cervical Cancer

• Linus T. Chuang, MD
• Mt. Sinai School of Medicine

2
Cervical Cancer

• Second most common female cancer
• Incidence 500,000
• Death 270,000
• Standard treatments
• Radical hysterectomy
• Chemo-radiation therapy

3
Incidence
41
SEER Cancer Statistics Review 19752005
4
Radical Hysterectomy

• Stage IB1 and IIA cervical cancer
• Approaches
• Abdominal lymphadenectomy
• Vaginal laparoscopically lymphadenectomy
• Laparoscopic lymphadenectomy
• Laparoscopic-assisted robotic lymphadenectomy

5
Sensitivity and Specificity of Imaging Studies
for Pelvic Nodes in Cervical Cancers
CT scan positive predictive value 60,
negative predictive value 91
Childers J Gynecologic Oncology 47, 38 (1992)
6
PET Scan Evaluation of Locally Advanced Cervical
Cancer
Yildirim et al.
7
Radical Hysterectomy
8
Fertility Sparing Surgery
9
Fertility Sparing Surgery
10
Vaginal Radical Trachelectomy (VRT)
11
VRT

• The vaginal mucosa is injected to separate the
  planes of dissection.

Sonoda Y, Abu-Rustum NR.Gynecol Oncol. 2007
Feb104(2 Suppl 1)50-5.
12
VRT

• The vaginal mucosa is incised. The outer layer is
  incised completely only anteriorly and
  posteriorly. The lateral incisions are shallow.

13
VRT

• The vaginal mucosa is folded over the cervix.

14
VRT

• The posterior cul de sac is entered.

15
VRT

• The pararectal space is opened to isolate the
  uterosacral ligaments.

16
VRT

• The uterosacral ligament is divided.

17
VRT

• The vesicouterine space is developed with sharp
  dissection.

18
VRT

• The paravesical space is opened.

19
VRT

• The knee of the ureter can be palpated in the
  bladder pillar.

20
VRT

• The bladder pillar can be divided to allow for
  more descensus.

21
VRT

• Two clamps are used to divide the parametrium
  once the ureter is assured to be away.

22
VRT

• The cervicouterine branch of the uterine artery
  is divided.

23
VRT

• Amputating the cervix.

24
VRT

• A cerclage is placed to help support the cervix.

25
VRT

• Final reconstruction of vagina to residual
  cervix.

26
VRT
27
Abdominal Radical Trachelectomy (ART)

• Smith JR, Boyle DC, Corless DJ, Ungar L, Lawson
  AD, Del Priore G, McCall JM, Lindsay I, Bridges
  JE. Br J Obstet Gynaecol. 1997 Oct104(10)1196-20
  0.
• Abu-Rustum N, Sonoda Y popularized the procedure

28
Eligibility Criteria for ART

• Confirmed invasive cervical cancer squamous,
  adenocarcinoma, or adenosquamous
• FIGO Stage IA2 to IB1
• Age lt 45 years and strong desire to preserve
  fertility
• No clinical evidence of impaired fertility
• Lesion size  4 cm
• Chest X-ray with no evidence of metastasis.
  Preoperative MRI of pelvis  abdomen, or
  appropriate imaging protocol
• 46 weeks post conization with adequate
  resolution of acute inflammation

Abu-Rustum N et al. Gynecol Oncol. 2008
Nov111(2)261-4.
29
Abdominal Radical Trachelectomy (ART)

• The uterus is manipulated by clamps on the round
  ligaments avoiding the utero-ovarian pedicles.

30
ART

• The uterine vessels are then ligated and divided.
  
• The parametria and paracolpos with uterine
  vessels are mobilized medially with the specimen.
  
• A complete ureterolysis is performed.
• The posterior cul de sac peritoneum is incised
  and the uterosacral ligament divided.
• The parametria and paracolpos are divided.

31
ART

• After completely separating the parametria,
  ligating the uterine vessels at their origins and
  completing the ureterolysis, an anterior colotomy
  is performed facilitated by a vaginal cylinder.

32
ART

• A Wertheim clamp can be used to determine the
  vaginal resection margin.

33
ART

• Clamps are placed at the level of the internal
  os.
• Using a knife, the radical trachelectomy is
  completed by separating the fundus from the
  isthmus or upper endocervix at approximately 5 mm
  below the level of the internal os.

34
ART

• Endometrial and upper endocervical curettage as
  well as a shave margin on the remaining tissue is
  sent for frozen-section.
• Frozen section is obtained on the endocervical
  margin.
• Frozen section is obtained circumferentially on
  the vaginal cuff.

35
ART

• A permanent cerclage with 0 Ethibond is placed
  and the knot tied posteriorly.

36
ART

• Reconstruction of the uterine corpus to upper
  vagina after the cerclage is placed.

37
ART

• The uterine fundus is reattached to the vaginal
  apex with 6 to 8 interrupted 2-0 absorbable
  sutures.

38
ART

• The reconstructed fundus with remaining blood
  supply from the intact utero-ovarian
  ligamentsuterine serosa without evidence of
  fundal ischemia.

39
Robotic Radical Trachelectomy (RRT)

• Chuang L et al, Fertility-sparing
  Robotic-assisted Radical Trachelectomy and
  Bilateral Pelvic Lymphadenectomy in Early-stage
  Cervical Cancer Journal of Minimally Invasive
  Gynecology, Vol 15, Issue 6, 2008, Pages 767-770
  .
• Burnett A, Robotic radical trachelectomy and
  pelvic lymphadenectomy in early cervical cancer,
  Gynecol. Oncol. 112 (2009), p. S8.
• Six cases reported

40
Intraoperative Margin Assessment

• The peripheral soft tissue including the
  parametria is inked green while the LUS/EC
  margins are inked blue.
• In some cases, the tumor will appear in the
  frozen section at lt 5 mm from the margin.
• In these cases, the LUS margin is revised.

Ismiil N, et al Gynecol Oncol. 2009
Apr113(1)42-6.
41
Intraoperative Margin Assessment

• The margin was reported as negative in 123,
  suspicious in 3 and positive in 6 cases.
• It was revised in 16 cases (6 positive, 2
  suspicious and 8 negative but lt 5 mm).
• Final margin assessment agreed with the FS
  diagnosis in 130 (98.5).
• No false negative intraoperative assessment was
  found.

Ismiil N, et al Gynecol Oncol. 2009
Apr113(1)42-6.
42
Parametrial Lengths
Einstein MH, et al Gynecol Oncol. 2009
Jan112(1)73-7.
43
RH vs VRT/ART

• No statistical differences between the two groups
  
• median number of lymph nodes removed (26 vs 28)
• node positive rate (15 vs 8)
• The 5-year recurrence free survival rate
• 96 (for the RT group compared to
• 86 for the RH group
• P  NS

Diaz JP et al Gynecol Oncol. 2008
Nov111(2)255-60.
44
ART

• Median time in the operating room was 298 min
  (range, 180425).
• Median estimated blood loss was 250 ml (range,
  50700).
• Median hospital stay was 4 days (range, 36).
• No recurrence.

Abu-Rustum NR, et al Gynecol Oncol. 2008
Nov111(2)261-4.
45
Cytologic Findings after RT

• An endometrial component was identified in 131 of
  the cases (59).
• Twenty-eight cases were diagnosed as abnormal.
• The biopsies confirmed the presence of a lesion
  in only 4 of 25 biopsies
• 3 low-grade squamous intraepithelial lesions
• 1 adenosquamous carcinoma
• All cases diagnosed as atypical glandular cells
  represented tubal metaplasia, lower uterine
  segment glandular cells, or endometrial stromal
  cells.

Feratovic R, et al Cancer. 2008 Feb
25114(1)1-6.
46
Cytologic Findings after RT

• Lower uterine segment glandular cells.
• Endometrial stromal cells.
• Tubal metaplasia.

Feratovic R, et al Cancer. 2008 Feb
25114(1)1-6.
47
Fertility Preserving Surgery

• Over 900 cases have been performed.
• Most have been carried out vaginally (radical
  vaginal trachelectomy and laparoscopic pelvic
  node dissection).
• A smaller number have been performed abdominally.
  
• Over 300 pregnancies reported with 196 live
  births.
• 10 significant prematurity rate with birth prior
  to 32 weeks.
• 31 recurrences (4), and 16 deaths (2).

• Milliken DA, Shepherd JH. Curr Opin Oncol. 2008
  Sep20(5)575-80.

48
Phase II trial of neoadjuvant paclitaxel and
cisplatin in uterine cervical cancer

• Stage IB2 to IIB
• Paclitaxel 60 mg/m2 followed by cisplatin 60
  mg/m2 every 10 days and for three courses.
• 43 patients were enrolled in this study and all
  of them were given an operation.
• Hematologic toxicity was seen in 17 patients. But
  most of them were anemia and there was no grade 3
  or 4.
• Grade 1 neurotoxicities developed in 29 patients
  and all of them were peripheral neurotoxicity.

• Park DC, et al Gyn Oncol 92 (1) 59-63, 2004

49
Phase II trial of neoadjuvant paclitaxel and
cisplatin in uterine cervical cancer

• Park DC, et al Gyn Oncol 92 (1) 59-63, 2004

50
ART in First 10 Patients

• Ten patients underwent radical abdominal
  trachelectomy.
• Two patients achieved pregnancy
• 1 twin delivery
• 1 patient had 2 pregnancies.
• Two patients experienced cervical stenosis with
  regular menses and the same 2 patients passed
  their abdominal cerclage vaginally.
• To date there have been no cancer recurrences.

Olawaiye A, et al Gynecol Oncol. 2009
Mar112(3)506-10.
51
ART in First 10 Patients

• The experience was based on ten cases performed
  at Massachusetts General Hospital.
• Surgery was essentially identical to that of
  radical hysterectomy with the exception of
  re-anastomosis of the uterine fundus to the
  vagina and placement of cerclage.
• Radical abdominal trachelectomy can be
  successfully performed by any gynecologic
  oncologist who is trained in radical pelvic
  surgery.

Olawaiye A, et al Gynecol Oncol. 2009
Mar112(3)506-10.
52
Radical Trachelectomy

• A viable option for nulliparous women who desires
  future childbearing.
• Ideal candidates are those with stage Ib1
  cervical cancer with no metastasis.
• Abdominal trachelectomy is easy to be adopted by
  experienced gynecologic oncologist.
• Over 200 live births reported.
• Compatible recurrence and death rate as radical
  hysterectomy.

53
Thank You