As the incidence of cervical cancer is getting younger, which patients can retain their fertility?
When it comes to which patients can preserve their fertility, firstly, she should have a strong demand for fertility and be willing to take certain risks of tumor recurrence or metastasis. Secondly, it depends on the stage of the disease. We know that cervical cancer is divided into 4 stages according to the International Federation of Gynecology and Obstetrics (FIGO) staging system, and each stage can be subdivided into IA1, IA2, IB1, IB2 or IIA1, IIA2, etc.. Among them, IA1 and IA2 belong to microscopic early invasive carcinoma, with infiltration not exceeding 3 mm as IA1 and between 3-5 mm as IA2, while 1 and 2 in IB1, IB2 or IIA1 and IIA2 are intended to suggest the size of the mass. If the maximum diameter of the mass is more than 4 cm, it is IB2 or IIA2, which is a large mass. Among them, those who are staged as IA1, IA2, IB1 and meet other conditions can be considered to preserve their reproductive function. Again, it is related to the nature of cervical cancer. Squamous cervical cancer and adenocarcinoma meet the above two requirements and can be considered for preserving reproductive function. However, some special types, such as cervical mucinous adenocarcinoma and small cell neuroendocrine tumor, are rare types with very rapid recurrence and metastasis, and fertility preservation is generally not recommended.
To summarize, young cervical cancer patients who strongly request fertility preservation and patients with stage IA1, IA2, and IB1 squamous, adenocarcinoma, or adenosquamous carcinoma of the cervix may be considered for fertility preservation.
Is there a critical line between preservable and high-risk?
Above we talked about the scope and conditions that can be preserved. There are some high-risk factors for recurrence and metastasis of cervical cancer that are detected by pathological examination, such as: parametrial infiltration, positive cut margins, positive lymph nodes, deep muscle infiltration, vascular involvement, and the specific pathological types mentioned above. All of these can affect the outcome of fertility preservation surgery.
For example, some patients have a relatively large mass that happens to be 4 centimeters from the critical lesion, and after the surgery is opened in, it is found that there are already many metastatic lesions inside. At that time, the uterus had to be completely removed and fertility could not be preserved.
There are also some patients who are found to have infiltration of the vasculature during surgery, and preserving fertility has the risk of recurrence of metastasis in the short term. Usually, for patients with stage IA2 or IB1 cervical cancer, or stage IA1 patients with vascular infiltration, we first do lymphatic dissection during surgery and all lymph nodes are taken for frozen section. If the results show that the lymph nodes have metastasized, the uterus cannot be preserved. Of course, there are some patients who show negative lymph nodes in the intraoperative frozen section, but the postoperative pathological diagnosis is reported positive again. At this point, the patient has a very difficult decision to make, whether to have a second surgery, remove the uterus, or adjuvant radiotherapy, which destroys fertility, or to risk adjuvant chemotherapy, complete fertility, and continue treatment.
Again, another common reason that may influence a change in surgical approach is a positive cutting edge. A patient who is able to successfully preserve the uterus should have a surgical margin free of any residual lesions and the margin should be at least 3 mm from their lesion.
For lymph node dissection, do you sweep the entire pelvic lymph nodes?
First, the highest pelvic lymph node, the common iliac lymph, should be swept. If the lymph biopsy is positive, fertility cannot be preserved and the lymph will have to be swept further up to the abdominal aortic lymph nodes.
If the surgery preserves the uterus but the lymph nodes are found to be positive postoperatively, can fertility be preserved through adjuvant therapy?
In this case, we will give the patient an in-depth conversation and tell her the pros and cons of the various treatment options that are available as mentioned earlier: continued surgery, radiotherapy, or chemotherapy. For patients with a strong desire to have children, we recommend that the patient complete at least 4 courses of chemotherapy. Prior to chemotherapy, prophylactic medication can be administered to protect ovarian function appropriately. After chemotherapy, if menstruation can be resumed on time, there is a chance of fertility. However, radiotherapy should not be done. Radiotherapy will completely destroy the bad ovarian function, leading to uterine cavity adhesion, radioactive amenorrhea and complete loss of ovulation function of ovaries.
Does fertility preservation for cervical cancer patients mean preserving the uterus? How can it be preserved? Will it lose its support and prolapse?
Fertility preservation in cervical cancer patients means preserving the body of the uterus (where the fetus grows and develops). The uterus is divided into two parts, including the body and the lower part of the cervix. In patients with cervical cancer, the lesion grows on the cervix. Surgery for fertility-preserving cervical cancer requires, on the one hand, the removal of a sufficient amount of the lesion and its surrounding tissue (the excised portion is removed vaginally) and, on the other hand, the preservation of the normal body of the uterus.
There is a concern that the preserved uterus will lose its support and will not stay in place. This concern is actually superfluous. The uterus is maintained in this position in the pelvis by a series of ligaments that tug on it and suspend it in the pelvis like a hammock. The surgery requires the removal of the lesion of the cervix, as well as part of the main ligament and the uterosacral ligament. However, the round ligament and part of the broad ligament are kept intact, and there is a lot of fibrous connective tissue that holds the uterus together. Moreover, after removal of the diseased cervix, the lower end of the uterus and the vaginal wall need to be sewn back together. In general, the uterine body remains suspended in the pelvic cavity after surgery, relatively fixed, rather than wobbling around.
How long after surgery can I get pregnant?
Contraception is recommended for about two years after surgery. This time is mainly for the repair of the lower end of the uterus. The surgery cuts off a large piece of the cervix and the lower end of the uterus is left almost open. During the operation, we will use a polypropylene sling and tie the lower part of the uterus tightly, which is equivalent to artificially creating a section of the cervix. This wound will take some time to repair, and if you get pregnant too early, the “cervix” may not be fully functional and you may miscarry.
If I have chemotherapy after surgery, how long will it take to get pregnant?
It is also two years for contraception. The length of time is not extended by chemotherapy.
Is there any difference in follow-up between patients with cervical cancer who have preserved their uterus and other patients?
This is important, and there are indeed some differences. Patients with preserved uterus require more frequent follow-up.
For the first two years after surgery, they have to come in for follow-up every 3 months. Each time, they have to be checked for HPV and have a TCT smear. These are indicators that are closely related to the causation of cervical cancer. If it continues for 1-2 years and HPV is all high risk positive and does not turn negative, and the TCT shows abnormalities, you need to be treated again, preferably with extensive surgical removal of the body of the uterus.
Can these patients have children naturally, or do they need assisted reproduction?
Most patients are able to have children spontaneously and are encouraged to do so. If there are other preoperative factors of infertility, such as tubal obstruction or ovarian hypofertility, assisted reproduction is required.
Do these patients have a higher risk of miscarriage and preterm delivery than others?
Yes. There are many reasons for this.
The rate of miscarriage and preterm delivery in the general population is generally less than 10%. According to international data, after cervical cancer surgery that preserves fertility, 40% of people will actually change their minds about not having children, or their conditions will not allow them to have children. Of the remaining 60 percent who want to have children, 60 percent are able to get pregnant; however, about half miscarry in the early stages. About 1/4 of those who eventually manage to have a baby are slightly above this percentage for patients operated on in our hospital. There are also isolated reports of 60-70% fertility rates.
Can it prevent miscarriage and premature birth?
The purpose of sewing a sling on the lower part of the uterus during surgery is to prevent and reduce the chances of miscarriage and preterm birth. This sling is non-absorbable and will remain tied there.
Does it also have a preventive effect when a woman lies down more after conception and the fetus is smaller?
Yes, bed rest itself is the most effective way to preserve the fetus. Bed rest, when the uterus is under lower tension, works even better than the use of progesterone. However, it is important to note that the longer you stay in bed, the higher the risk of thrombosis. A smaller fetus, with less pressure on the uterus, also helps prevent preterm delivery compared to a huge baby.
What conditions occur in these patients to stop the pregnancy?
This needs to be considered from both the mother and the fetus.
First, the pregnancy needs to be stopped if the fetus shows abnormal fetal movements or no fetal heartbeat or signs of miscarriage, if the fetus or the sac has fallen to the vaginal opening, or if the fetus has any abnormality.
Secondly, for the mother, if there are problems that may threaten her own safety, such as progression of the lesion, recurrence, metastasis, and residual lesions, all of which are unfavorable, the pregnancy needs to be terminated.
What if the woman insists on keeping the pregnancy?
We did encounter such a situation.
This patient was 18 weeks and 3 days pregnant when she came to our clinic. She was preoperatively 1B1 with a large lesion that was exactly 4 centimeters full. She happened to have stage 1B1 cervical mucinous adenocarcinoma, and many hospitals she saw in Jiangsu and Zhejiang were advising her to terminate her pregnancy and have her uterus cut out. This is also the standard treatment plan. However, she did not want to give up her first pregnancy, and we also wanted to make her whole, as she would never have a chance after the uterus was removed.
Therefore, at the patient’s request, we prepared well and performed a laparoscopic pelvic lymph node dissection + extensive hysterectomy. During the operation, we found that the lesion was large and the upper cervical margin was very close to the fetal membranes. If the cut was higher, the cutting edge could be taken more, but the fetal membranes were likely to rupture. However, it was not possible to cut too little in order not to leave residual lesions. We also sewed up the opening of the lower end of the uterus in order to save the baby.
After the operation, she also experienced a lot of shocks. We had advised her to give up, but she refused to give up the opportunity to be a mother and was willing to take the risk because the postoperative pathological section showed infiltration of her lymphatic vasculature and the surgical cut edge was less than 3 mm from the lesion. So she was given additional chemotherapy while continuing her pregnancy. She had chemotherapy 3 times during the whole pregnancy.
Generally, chemotherapy is not recommended in early pregnancy, 1 month before delivery, for fear that the drugs will affect the fetus. During mid-pregnancy, there are many reports on the safety of chemotherapy. Fortunately, the chemotherapy was completed very successfully.
In the meantime, we asked the patient to be bedridden at all times. Finally, we performed a cesarean section on her, and after the fetus came out, a hysterectomy was done immediately. And after the operation, she was supplemented with simultaneous radiotherapy. It has now been more than 1 year since her delivery. Follow-up visits revealed that the patient is recovering well and the baby is healthy.
Similar cases have been reported internationally in more than a dozen cases, with the majority of successful pregnancies. What makes us different from other international cases is that most of them did open and negative surgery, while we are the world’s first to continue pregnancy after extensive laparoscopic hysterectomy in mid pregnancy.
What are the dietary and care considerations for these women once they become pregnant?
Once pregnant, they are pretty much the same as regular pregnant women in terms of diet, with normal intake of fruits, vegetables, milk, eggs, and other foods.
It is important to note that some of these patients have had extensive cervical excision and some of their nerves that connect urination and connection to defecation can be damaged during surgery. The nerves will take some time to repair and the reflexes will not be established as well as normal. Therefore, these women should develop very good urination and defecation habits, drink more water, not eat too much spicy, greasy and irritating food, and avoid dry stools.
Then there is the need to realize that they are a high-risk pregnancy, prone to miscarriage, and early bed rest is necessary.
Some patients with precancerous cervical lesions worry that the change of estrogen and progesterone level in their body during pregnancy will affect the course of the disease; some are also worried that the use of conization treatment will affect the pregnancy. Is there such a situation?
The cause of cervical cancer is HPV infection, which is not an estrogen-sensitive disease. Therefore, pregnancy does not alter the prognosis of cervical cancer or precancerous lesions. Clinical data show that the overall recurrence and metastasis rates of patients with cervical cancer in combination with pregnancy are no different from those of ordinary patients.
Cervical precancerous lesions are mainly treated by conization. It has no effect on pregnancy after surgery. If you are already pregnant and undergo conization, as long as the conization does not affect the fetus, fetal membranes and placental integrity, you can follow up closely and do not necessarily terminate the pregnancy.