laparoscopic pelvic lymphadenectomy …...prezentãm un caz de limfadenectomie pelvinã cu...

Obstetrica }i Ginecologia 113

Obstetrica }i Ginecologia LXVI (2018) 113-119 Case Report

CORESPONDENCE: Cristina Secosan, email: [email protected]

KEY WORDS: radical trachelectomy, surgery, cervical cancer, lyphadenectomy, laparoscopy, cerclage, nulliparous

LAPAROSCOPIC PELVIC LYMPHADENECTOMY WITHVAGINAL RADICAL TRACHELECTOMY IN A NULLIPAROUSPATIENT WITH EARLY STAGE CERVICAL CANCER– CASE

REPORT

L. Pirtea1, Cristina Secosan1,, G. Crãciun2, Lavinia Bãlan2, Gina Baltã2, Porfira Bostinã2,Ligia Bãlulescu2, D. Grigoras1

1Department of Obstetrics and Gynecology, University of Medicine and Pharmacy “VictorBabes” Timisoara, Romania2 Department of Obstetrics and Gynecology, County Hospital Timisoara, Romania

Abstract

Radical trachelectomy is considered standard of care in patients with early-stage cervical cancer interestedin future fertility. Fertility-sparing radical trachelectomy appears to have similar surgical and oncologic outcomesto more extensive radical procedures in selected patients with early stage cervical cancer. Tumors of 2 cm orless are considered to have a lower risk of parametrial involvement, a more favorable 5-year overall survival rateand a better fertility outcome. Nevertheless, pregnancies after trachelectomy should be considered as high risk. Theprocedure requires advanced vaginal surgical skills when performed in nulliparous women. We present a case oflaparoscopic pelvic lymphadenectomy with vaginal radical trachelectomy performed in our clinic on a nulliparouspatient diagnosed with FIGO stage IA1 cervical cancer, who desired to preserve her fertility. Sentinel node mappingusing methylene blue and cerclage placement at the end of the procedure were also performed.

Rezumat

Trachelectomia radicalã este consideratã tratamentul standard pentru pacientele cu cancer de col uterinîn fazã incipientã care doresc sã îi pãstreze fertilitatea. Conservarea fertilitãtii prin aceasta procedurã chirurgicalãnu pare sã pericliteze rezultatele oncologice în cazuri selectate cu cancer cervical incipient. Tumorile de 2 cm saumai putin sunt considerate a avea un risc scãzut de invazie parametrialã, o supravietuire globalã la 5 ani maifavorabilã si rezultate mai bune din punct de vedere al fertilitãtii. Cu totate acestea, sarcinile obtinute dupãtrachelectomie radicalã trebuie considerate ca fiind cu risc crescut. Trachelectomia radicalã vaginalã necesitãabilitãti chirurgicale vaginale avansate atunci când este efectuatã la nulipare. Prezentãm un caz de limfadenectomiepelvinã cu trachelectomie radicalã efectuat în clinica noastrã la o pacientã nuliparã diagnosticatã cu cancer decol uterin stadiul FIGO IA1, care dorea conservarea fertilitãtii. În timpul interventiei chirurgicale s-au efectuat deasemenea identificarea ganglionului santinelã folosind albastru de metilen si aplicarea unui cerclaj la finalulprocedurii.

Cuvinte cheie: trachelectomie radicalã, chirurgie, cancer de col uterin, limfadenectomie,laparoscopie, cerclaj, nuliparã.

Introduction

Early stage cervical cancer diagnosed inyoung women who desire to preserve their fertilityremains an issue, given that radical hysterectomyinvolves by definition the loss of the uterus. This has

led to a questioning of the rationale for extensivesurgery in all cases of early stage cervical cancer. In1987 Dargent described for the first time the vaginalradical trachelectomy with lymphadenectomy as a

114 Obstetrica }i Ginecologia

fertility sparing treatment of early-stage cervicalcarcinoma [1, 2].

Radical trachelectomy is recommended forearly stage cervical cancer (stages IA1-IB1) withlesions <2cm. Nevertheless, advanced vaginalsurgical skills are required in order to perform a radicalvaginal trachelectomy in nulliparous patients.

The procedure can be performed vaginallyor abdominally, using an open or laparoscopictechnique. The evaluation of the pelvic lymph nodesstatus remains a subject of debate. While the sentinellymph node detection method is tempting and can aidin intraoperatory decision making (if the sentinellymph nodes are negative the trachelectomy can beperformed, whilst if they are positive a radicalhysterectomy followed by chemo-radiotherapy isrecommended), the high rate of false negative resultscauses it not to become the “gold standard”. Pelviclymphadenectomy can be performed by laparoscopy(the original technique described by Dargent involvesradical vaginal trachelectomy with laparoscopic pelviclymphadencetomy) [2], or by laparotomy. At the endof the procedure, a cerclage is usually placed. It isimportant to note that cerclage placement is alsorecommended in the second trimester of pregnancyif not prior performed [5].

Case report

We present the case of a 40 year oldnulliparous patient diagnosed with FIGO stage IA1cervical cancer who underwent laparoscopic pelviclymphadenectomy with vaginal radical trachelectomyin our clinic.

Upon clinical examination, a 5 mm ulcerativelesion located on the posterior cervical lip wasidentified. A colposcopic guided biopsy revealed aninvasive epidermoide carcinoma. Preoperative MRIevaluation revealed radiologically normal pelvic lymphnodes. The patient was informed regarding treatmentoptions and, given her desire of fertility preservation,the chosen treatment was laparoscopic pelviclymphadenectomy followed by vaginal radicaltrachelectomy.

Step by step description of the surgicaltechnique:

Sentinel lymph node mapping was performedby injecting methylene blue in the cervix prior tobeginning the surgical procedure (Figure 1).

Four laparoscopic trocars were placed. Theprimary 12-mm trocar was placed in the umbilicalregion, whereas the other 3 accessory trocars wereplaced as follows: 10 mm in the right iliac fossa, 5

Figure 1 Sentinel node mapping using methylene blue

Laparoscopic pelvic lymphadenectomy with vaginal radical trachelectomy in a nulliparous patient with early stage cervicalcancer– case report


mm in the left iliac fossa, and 5 mm in the suprapubicregion. The patient was placed in the Trendelenburglithotomy position, with compression stockings wornduring surgery to prevent thromboembolic events. Inaddition, antithrombotic prophylaxis with low–molecular weight heparin was used. The uterus wasmobilized by placement of a manipulator.

Pneumoperitoneum was established andmaintained with a pressure of 12 mmHg.

The peritoneum was sectioned in front andbehind both round ligaments, parallel to the ovarianvessels. The retroperitoneum was exposed up to thejunction of the ureter with the iliac artery. A bilateralpelvic lymphadenectomy was performed from thecircumflex vein to the junction of the ureter with theexternal iliac artery. The external iliac, hypogastric,

and obturator lymph nodes were completely removed.The pelvic lymph nodes were intraoperativelyevaluated.

With the patient placed in gynecologicalposition we performed a circular incision of the vaginalmucosa resulting a „vaginal cuff” (Figure 2A). Thenext step was the opening of the retroperitoneumwhich allowed us to perform the bilateral dissectionof the pararectal fossae (Figure 2B). The openingof the cervical-vesical plan (Figure 2C) permitted thebilateral dissection of the paravesical fossae (Figure2D) followed by the bilateral dissection and resectionof the bladder pillars (Figure 3A).

Before performing the bilateral resection ofthe paracervix (Figure 3B- right paracervix, Figure3C - left paracervix) we had to realize the bilateral

Figure 2: A-incision of the vaginal mucosa resulting the vaginal cuff; B-opening of the retroperitoneum; C-opening of the cervical-vesical plan; D- dissection of the paravesical fossae

L. Pirtea


dissection and resection of the uterosacral ligaments.The final step was the cervix removal followed bythe uterine isthmus’ suture to the vagina. At the end,a prophylactic cerclage was placed (Figure 3D).

Discussions

Case selectionRadical trachelectomy is recommended for

stage IA2, for stage IB1 and for stage IA1 with lymphvascular space involvement [1] in patients interestedto maintain their reproductive capacity [1, 6]. Tumorsof 2 cm or less are considered to have a lowerrisk of parametrial involvement and a more favorable5-year overall survival rate. [6-10].

While other authors consider that patientswith 2-4 cm tumors can undergo trachelectomy safely

[11], others believe that a lesion with the size >2 cmis associated with a higher risk of recurrence and ahigher risk of abandoning the planned radical vaginaltrachelectomy [3, 5, 12-14].

Less or more invasive surgery?Radical trachelectomy is considered standard

of care in patients with early-stage cervical cancerinterested in future fertility. Described as a safe andeffective treatment even during pregnancy [15],fertility-sparing radical trachelectomy appears to havesimilar surgical and oncologic outcomes to moreextensive radical procedures in selected patients withearly stage cervical cancer [11, 16, 17].

Tseng et al performed a retrospective studyon 2571 patients under 45 years old who underwentless radical surgery (LRS - conisation, trachelectomy,

Figure 3: A-dissection and resection of the bladder pillars; bilateral resection of the paracervix B-rightparacervix, C-left paracervix; D-cerclage placement.



L. Pirtea

standard hysterectomy) or more radical surgery(MRS - modified radical, radical hysterectomy) forFIGO stage IB cervical cancer, all with lymph nodeassessment (807 underwent LRS and 1764underwent MRS) with a 10 years follow-up period.They concluded that in a select group of youngwomen with stage IB1 cervical cancer, LRScompared to MRS does not appear to compromisedisease specific survival [14].

Marchiole et al compared the results in termsof fertility, complications and recurrence of earlystage cervical cancer (I-IIA) of 257 patient whounderwent laparoscopic assisted radical vaginaltrachelectomy (LARVT) (118 patients) or laparocopicassisted radical vaginal hysterectomy (LARVH) (139patients). They concluded that early cervical cancer(less than 2 cm diameter) can be treated successfullywith LARVT with similar efficacy and recurrencerates to LARVH. Therefore, radical trachelectomycan be considered a safe treatment for young womenaffected by early cervical cancer who want toconserve their fertility [7].

Open or minimally invasive?Open abdominal radical trachelectomy offers

better resection of the margins but is associated withlonger hospitality stays, more blood loss and woundcomplications in comparison with radical vaginaltrachelectomy which includes reduced length ofhospital stay, less blood loss, lower analgesicrequirements during the postoperative period, adecrease in the rate of blood transfusions, a decreasein the rate of complications, an early recovery ofphysiological functions, and better esthetic outcomes[4, 18].

Viera et al evaluated 100 patients with early-stage cervical cancer who underwent open (58patients) vs. minimally invasive radical trachelectomy(42 patients) and compared operative, oncologic, andfertility outcomes. Their results suggest that minimallyinvasive radical trachelectomy results in less bloodloss and a shorter hospital stay. Fertility rates appearedto be higher in patients with open radicaltrachelectomy, but the mean follow up period beinglonger for the open radical trachelectomy group, theresults are not conclusive in this matter [19].

Sentinel node mappingSentinel lymph node biopsy is apparently a

good predictor of node metastases and allows theperformance of lymphadenectomy only in sentinellymph node positive cases. [6] Despite it being veryuseful in clinical practice, until lower false-negativerates are achieved total lymphadenectomy remainsthe gold standard [20].

Fertility after the procedureThere can be no guarantee of future fertility

after a radical trachelectomy and, according toseveral authors, the standard treatment for early-stagecervical carcinoma remains radical hysterectomy.Therefore, full disclosure to the patient and a detailedinformed consent are essential prior to the surgicalprocedure [21-24].

Infertility has been reported in 25–30% ofpatients after trachelectomy and possible causes includesubclinical salpingitis or cervical stenosis. When suchcomplications occured, they resulted in menstrualdisorders, fertility problems or decreased cervicalmucus. Surgical dilatation resolved this problem in mostcases but had to be repeated [25-26].

Favorable pregnancy and live birth rates havebeen reported after the procedure. Shephard et alfound a 5-year cumulative pregnancy rate of 52.8%among women trying to conceive [21], while Willowset al reported 469 pregnancies with a 67 % live birthrate among 1238 patients who underwent fertility-sparing surgery for early cervical cancer [27].

Regarding the obstetrical outcome, the mainproblem is the prematurity. Second trimestermiscarriage and premature rupture of membranes(with 10% of babies being significantly premature)following premature labor are complications relatedto trachelectomy because of the shortened cervix withabsence of mucus. This facilitates the ascendinginfections and can result in chorioamnionitis.Therefore, pregnancies after trachelectomy shouldbe considered as high risk [21, 26]. Cerclageplacement after trachelectomy seeks to decrease therisk of second trimester miscarriage due to theshortened cervix [4].


Patients with tumors d” 2 cm appear to havea higher pregnancy rate than patients with tumors 2-4 cm [11].

Cesarean section is recommended after 37weeks. A vaginal delivery could be dangerous becauseof the possibility of a lateral cervical tear extendingto the uterine arteries [1, 16].

Morbidity and ComplicationsRadical trachelectomy has certain risks such

as potential intraoperative complications of thebladder, ureter or rectum. Specific problems areassociated with radical trachelectomy such asamenorrhea or irregular bleeding, dysmenorrhea,excessive vaginal discharge, problems with thecerclage suture, isthmic stenosis, sexual inactivity anddysplastic smears [1].

Conclusions

Radical trachelectomy can be considered asafe treatment for young women affected by earlycervical cancer who want to conserve their fertility.The procedure is particularly difficult to perform innulliparous women and requires advanced vaginalsurgical skills, such as in our case.

Tumors of 2 cm or less are consideredto have a lower risk of parametrial involvement, amore favorable 5-year overall survival rate and abetter fertility outcome.

Albeit favorable pregnancy and live birthrates have been reported after the procedure,pregnancies after trachelectomy should be consideredas high risk.

Cesarean section is recommended after 37weeks in order to prevent cervical tears (especiallylateral tears that can affect the uterine arteries).

References

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16. Shepherd JH, Milliken DA. Conservative surgery forcarcinoma of the Cervix. Clinical Oncology. 2008;20(6):395–400. [PubMed]17. Diaz JP, Sonoda Y, Leitao MM et al. Oncologic outcomeof fertility-sparing radical trachelectomy versus radicalhysterectomy for stage IB1 cervical carcinoma. GynecolOncol. 2008 Nov;111(2):255-60.18. Kai-Jiang L, Qing L, Na-Na H, Juan W, Pei-Quan L,Ming-Fang R. Short term clinical outcomes of laparoscopicfertility preserving radical hysterectomy in themanagement of early stage cervical cancer. Acta AcademiaeMedicinae. 2011;33(4):436–439.19. Vieira MA, Rendón GJ, Munsell M et al. Radicaltrachelectomy in early-stage cervical cancer: A comparisonof laparotomy and minimally invasive surgery. GynecolOncol. 2015 Sep;138(3):585-9.20. Abu-Rustum NR, Neubauer N, Sonoda Y et al.Surgicaland pathologic outcomes of fertility-sparing radicalabdominal trachelectomy for FIGO stage IB1 cervicalcancer. Gynecol Oncol. 2008 Nov;111(2):261-4.21. Shepherd JH, Spencer C, Herod J, Ind TEJ. Radicalvaginal trachelectomy as a fertility-sparing procedure inwomen with early-stage cervical cancer—cumulativepregnancy rate in a series of 123 women. An InternationalJournal of Obstetrics and Gynaecology. 2006;113(6):719–724.

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L. Pirtea

laparoscopic pelvic lymphadenectomy …...prezentãm un caz de limfadenectomie pelvinã cu...

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