Setting & Treatment
In our hospital, fertility-sparing treatment options for cervical cancer include VRT with Sentinel Node Procedure (SNP) and Pelvic Lymph Node Dissection (PLND), radical hysterectomy (RH) with ovarian preservation and fertility preservation (FP) procedures prior to (chemo)radiotherapy.
After standardized diagnostic workup including medical history, physical examination, laboratory tests, MR-imaging and histopathological analysis, an individualized treatment plan was made during weekly multidisciplinary treatment meetings. Staging was done according to the International Federation of Obstetrics and Gynecology 2018 classification 6. Available treatment options included:
1) VRT with laparoscopic or robotic SNP and PLND was indicated in IA2-IB1 tumors measuring ≤2 cm as recommended by international guidelines 6, 10. Our surgical technique was previously described by 7, 11 and included SNP with frozen section (FS) analyses, complete PLND and a vaginal radical trachelectomy. A 2-step procedure consisting of a separate laparoscopic or robotic SNP and PLND procedure with serial sectioning was performed in patients with an estimated risk of lymph node (LN) positivity of >10% to rule out lymph node metastases. In absence of LN metastases, a VRT was performed in a second session. In these cases the FS was not performed and final histopathology determines whether or not the VRT was performed or chemoradiotherapy was required. A complementary radical hysterectomy was performed in presence of positive or close surgical margins and adjuvant chemoradiation was recommended in case of positive lymph nodes. Neo-adjuvant chemotherapy followed by VRT was performed on an individualized shared decision making basis.
2) Robot-assisted radical hysterectomy with SNP and PLND was indicated in FIGO stage IB2 and IIA1 disease 6. As previously described, first the SNP was performed and sent for FS analyses before the PLND was completed using the da Vinci robot 12.In absence of lymph node metastases, a radical hysterectomy was performed. Adjuvant radiotherapy was indicated in presence of deep cervical stromal invasion, lymphovascular space invasion (LVSI) and large (> 4cm) tumor size 13, 14. Adjuvant chemoradiotherapy was recommended for patients with LN metastases or (microscopic) parametrial involvement 14.
3) For patients with stage IB3 to IVA stage disease, treatment consisted of concurrent external beam chemoradiotherapy followed by MRI guided brachytherapy performed by a radiation oncologist 15.
Routine follow-up visits were performed every 3 months for the first year, every 4 months for the second year and biannually for the last three years.