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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: Obstet Gynecol. 2020 Sep;136(3):533–542. doi: 10.1097/AOG.0000000000003952

Radical Trachelectomy for the Treatment of Early-Stage Cervical Cancer: A Systematic Review

Evan S Smith a, Ashley S Moon b, Robin O’Hanlon c, Mario M Leitao Jr a,d, Yukio Sonoda a,d, Nadeem R Abu-Rustum a,d, Jennifer J Mueller a,d
PMCID: PMC7528402  NIHMSID: NIHMS1589960  PMID: 32769648

Abstract

Objectives:

To assess surgical, oncologic, and pregnancy outcomes in patients undergoing radical vaginal, abdominal, or laparoscopic trachelectomy for the treatment of early-stage cervical cancer, using a methodic review of published literature.

Data Sources:

PubMed, Embase, and Cochrane Library sources, including ClinicalTrials.gov, were searched from 1990 to 2019 with terms “cervical cancer” and “(vaginal, abdominal, open, minimally invasive, or laparoscopic) radical trachelectomy”. Grey literature and unpublished data were omitted.

Methods of Study Selection:

After removal of duplicates from a combined EndNote library of results, 490 articles were reviewed using Covidence software. Two reviewers screened titles and abstracts, and then screened full texts. Selection criteria included articles reporting radical trachelectomy with lymph node assessment as primary therapy for cervical carcinoma, with stated follow-up intervals and recurrences.

Tabulation, Integration, and Results:

Variables of interest were manually extracted into an electronic database. A total 47 articles reporting on 2566 women met inclusion criteria. Most tumors were of squamous histology (68.5%), stage IB1 (74.8%), <2cm (69.2%), and without lymphovascular invasion (68.8%). Of planned trachelectomies, 9% were converted intraoperatively to hysterectomy. Separated by route of trachelectomy, 58.1%, 37.2%, and 4.7% were performed using radical vaginal, abdominal, and laparoscopic approaches, respectively. With median follow-up of 48 months (range 2-202 months) across studies, median recurrence rate was 3.3% (range 0-25%); median time to recurrence was 26 months (range 8-44 months). Median 5-year recurrence-free and overall survival were 94.6% (range 88-97.3%) and 97.4% (range 95-99%), respectively. The post-trachelectomy pregnancy rate was 23.9% with a live birth rate of 75.1%.

Conclusions:

Radical trachelectomy for fertility-preserving treatment of cervical cancer is widely reported in the literature, though publications are mainly limited to case reports and case series. Reported follow-up periods infrequently meet standard oncologic parameters but show encouraging recurrence-free and overall survival rates and pregnancy outcomes. Higher-level evidence needed for meta-analysis is lacking.

Précis

Publications regarding radical trachelectomy are retrospective and heterogeneous in their reporting; however, collective results suggest encouraging surgical, oncologic, and pregnancy outcomes.

INTRODUCTION

Cervical cancer remains the fourth leading cause of cancer incidence and mortality in women worldwide, accounting for nearly 570,000 cases and over 311,000 deaths in a 2018 global estimate.1 New diagnoses in the United States (US) are most frequently detected among women aged 35-44 years.2 For those who wish to undergo treatment but preserve fertility, the National Comprehensive Cancer Network (NCCN) recommends highly selected patients with early-stage disease as eligible for fertility-sparing surgical treatment. Fertility-sparing options may include simple cervical cone biopsy, cone biopsy with pelvic lymph node assessment, or radical trachelectomy with pelvic lymph node assessment.3

The radical trachelectomy consists of en bloc removal of the cervix, vaginal margins, and parametria while leaving the uterine body and fundus in situ.4 Radical surgical methods include the classic Dargent radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy, abdominal radical trachelectomy, and total laparoscopic or robot-assisted laparoscopic radical trachelectomy, as previously described.4–16 Minimally invasive (MIS) procedures were the most commonly used approaches for trachelectomy in the US in 2015, according to a recent analysis of the National Cancer Database (NCDB). This reflects a change in practice among gynecologic oncologists and regression from majority use of the abdominal trachelectomy observed over a recent five-year period. The uptick in utilization of the MIS platform for trachelectomy parallels its use for radical hysterectomy over a similar time-frame.17

Differing surgical routes for the treatment of cervical cancer, however, may result in disparate oncologic results, as evidenced by the multicenter randomized Laparoscopic Approach to Cervical Cancer (LACC) trial.18 While the LACC trial addresses radical hysterectomy, its results provoke the question of whether these data can be extrapolated to any surgical intervention for cervical cancer. The retrospective International Radical Trachelectomy Assessment (IRTA) study is comparing survival metrics between open and minimally invasive radical trachelectomy19, but without published data from this study or other randomized trials, decisions regarding radical dissections for fertility-sparing treatments rely on a combination of results from observational research along with surgeon experience. Collaborative, wide-scale studies of this uncommon procedure are necessary to address the question of surgical technique and impact on outcomes.

Here we present a systematic review of published data regarding radical trachelectomy with lymph node assessment. Our primary aim is to assess oncologic outcomes and survival data collectively and when separated by surgical technique – vaginal, abdominal, and laparoscopic radical trachelectomy. Additional goals include an assessment of surgical parameters and pregnancy outcomes as they pertain to the differing surgical approaches along with a methodic appraisal of the quality of available medical literature.

SOURCES

A protocol registration was filed with the National Institute for Health Research’s PROSPERO international prospective register of systematic reviews under registration number CRD42019132443 and is publicly accessible online.20 Study design and result reporting was performed with guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.21

An electronic search of PubMed, Embase, and Cochrane Library sources from January 1990 to February 2019 was performed to collect publications of interest in any language and included in-press publications. Cochrane Library includes Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL). CENTRAL comprises records retrieved from PubMed (MEDLINE), Embase, ClinicalTrials.gov, World Health Organization’s International Clinical Trials Registry Program (ICTRP), KoreaMed, and all Cochrane Review Groups’ Specialized Registers. In order to include reports within the decade of Dr. Dargent’s early publications of the radical vaginal trachelectomy in 19944, 14, 1990 was set as the starting year. There were no restrictions set for article type, however grey literature and unpublished data were omitted. The PubMed search strategy included terms “cervical cancer” and “(vaginal, abdominal, open, laparotomy, laparotomic, minimally invasive, laparoscopic, robot(ic)-assisted, or keyhole) radical trachelectomy or cervicectomy”. Duplicates from search results were removed from a combined EndNote library of results. References were imported into the Covidence systematic review software for screening.22

STUDY SELECTION

Independent reviews of the reference titles and abstracts in separate scrambled order were performed by two authors (E.S. and A.M.) to assess for relevant articles. Full texts were then independently doubly-assessed for eligibility. Articles of interests were those with patients of all ages with cervical squamous, adeno-, or adenosquamous carcinoma or who underwent radical, fertility-sparing vaginal, abdominal, or laparoscopic (including robot-assisted laparoscopic) trachelectomy as the primary therapy. The surgical intervention must have included an operative assessment of lymph nodes, and the article describing treatment must have reported follow-up intervals and recurrences within that time to be included. Articles reporting cases of noninvasive or pre-malignant cervical lesions undergoing treatment through cervical cone biopsy or simple trachelectomy and cases using neoadjuvant chemotherapy or preoperative radiotherapy for treatment were excluded. Articles exclusively reporting on cervical cancer recurrence were not included for assessment.

For articles including patient data published in a prior series, such as articles with the same authors or similar methods detailing cases used in analyses, the earlier publications were excluded to ensure use of only the largest and most recent series and to prevent dataset inflation. Some comparative studies had data of interest for only one arm of patients in the study; if baseline characteristics were separated by cohort, data for the group of interest was included. Systematic reviews within articles were manually cross-referenced with the electronic search results to ensure a comprehensive collection of relevant publications; any additional relevant articles meeting criteria were included. Reasons for exclusion were recorded., Any conflicts of eligibility during the screening processes were resolved over a collaborative discussion between the two reviewers with input from the senior author (J.M.).

Data were independently extracted from eligible publications into an electronic database. Recorded variables included: first author, manuscript title, journal and year of publication, country of origin, type of study, type of intervention (vaginal, abdominal, or laparoscopic), planned number of trachelectomies, age, parity, histology, tumor size, stage (according to the International Federation of Gynecology and Obstetrics (FIGO) 1994–2009 staging systems), depth of invasion, presence of lymphovascular space invasion (LVSI), operative time, estimated blood loss, presence of nodal involvement, surgical margin positivity, conversions to hysterectomy, cohort size excluding hysterectomy, cohort receiving adjuvant radiation, months of follow-up, recurrences, median time to recurrence, deaths from disease, median survival time, disease-free survival (DFS) and overall survival (OS) with 95% confidence intervals, pregnancy status at time of trachelectomy, pregnancies after trachelectomy, and pregnancy outcomes (previable delivery or abortion, viable preterm delivery less than 37 weeks’ gestation, or term delivery).

The nine-question National Institutes of Health (NIH) Quality Assessment Tool for Case Series Studies was applied to all included publications as a means of individually evaluating study quality and measuring bias.23 Case series and cohort studies were subjected to all nine questions, but questions that did not apply to assessments of case reports were omitted and the quality scoring scale appropriately adjusted. A median follow-up period of at least three years was considered adequate for question 7, as this represents a period over which most early-stage cervical cancers will recur and is an established follow-up parameter for reporting in oncologic studies. Meeting less than 50% of the assessment tool items resulted in a “poor” rating, 50-80% a “fair” rating, and greater than 80% a “good” rating. Studies were not excluded from this review based on their quality score.

Narrative reports of results with descriptive statistics were provided for the previously mentioned variables, as appropriate. To calculate medians across grouped studies, study medians or means, whichever reported, were used as representative values for all subjects in the respective study. Ranges were provided using limits reflective of the median values used for studies within the groups. Thus, range limits do not reflect individual patient values within studies. Rates, reported as percentages, were calculated by dividing the affected number of cases by total number of cases available.

Not all studies published a standardized set of variables, thus denominators used for percentage reporting were adjusted accordingly. Also, divisors used for reporting oncologic outcomes within publications, specifically recurrence and death rates, varied greatly across studies. Some included all patients who underwent planned trachelectomy, some excluded those who underwent intraoperative or short-interval postoperative hysterectomy, and others excluded patients who received adjuvant therapy. Only reported variables were used for pooling of data within this study.

RESULTS

The electronic search yielded 1173 records: 562 from PubMed, 603 from Embase, and 5 from the Cochrane Library. The PRISMA process of article selection including abstract screening, full-text review, and exclusions, are shown in Figure 1. The most common reasons for excluding articles during the full-text review included study outcomes, such as those primarily reporting quality-of-life, reproductive, or pathologic outcomes without recurrence or survival data, or study designs, such as literature reviews or results from national cancer databases. After exclusions, 47 of the initial 490 screened studies were included for review. Accrued articles included 20 on vaginal radical trachelectomy, 18 on abdominal radical trachelectomy, and 12 on laparoscopic radical trachelectomy. Three of these studies included results of more than one route of radical trachelectomy, and two further stratified data by either extent of surgical resection or histology. This resulted in a total 52 sets of data for analysis. Most publications were case series (63.8%) which included 7 prospective and 23 retrospective case series. One article was a retrospective cohort study with only one relevant study arm, and the remainder were case reports (34%). Eligible publications were from 23 different journals; the most frequent publisher was Gynecologic Oncology (25.5% of articles). Years of publication ranged from 1999-2019 with most (70.2%) published within the last 10 years. Cases were reported from 25 different countries; the most frequently recurring country of case origin was the US (14.9% of articles) followed by China (12.8% of articles).

Figure 1.

Figure 1.

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Modified PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram detailing search strategy and exclusions.

The included articles identified a total 2566 women who underwent planned radical trachelectomy: 1491 (58.1%) through vaginal, 955 (37.2%) through abdominal, and 120 (4.7%) through laparoscopic approaches. Median age was 31 years (range 25-41 years), and most patients were nulliparous at the time of their procedure (64.1%). Most tumors were of squamous histology (68.5%); others were adenocarcinomas (26.2%), adenosquamous carcinomas (4.9%), or other histologies (0.4%). Tumor size was reported in two formats across articles: median size, which was 1.5 cm (range 0-3.5 cm), or number of cases with tumors less than or equal to two centimeters (69.2%) versus greater than two centimeters (30.8%). Median depth of tumor invasion was 5 mm (range 3-12 mm). Most patients had FIGO stage IB1 tumors (74.8%); the remainder were stage IA1 with LVSI (8.8%), IA2 (15.5%), IB2 (0.7%), or IIA (0.1%). Stage IIA tumors that underwent radical trachelectomy were upstaged after final pathology results due to positive vaginal involvement. Approximately one-third of tumors had LVSI (31.2%), thus the majority were without LVSI (68.8%). A breakdown of baseline characteristics within each patient group is shown in Table 1.

Table 1.

Baseline Patient and Pathology Characteristics of Women Undergoing Radical Trachelectomy

Characteristic Vaginal radical trachelectomy Abdominal radical trachelectomy Laparoscopic radical trachelectomy Total
Eligible datasets for data extraction*, n 21 18 13 52
Number of patients, n 1491 955 120 2566
Median age, years (range) 31 (27-41) 31 (26-38) 30.1 (25-36) 31 (25-41)
Parity, n (%)
 Nulliparous 120 (76.4) 415 (61.4) 68 (63) 603 (64.1)
 Parous 37 (23.6) 261 (38.6) 40 (37) 338 (35.9)
Histology, n (%)
 Squamous-cell carcinoma 967 (65.4) 661 (75.6) 67 (55.4) 1695 (68.5)
 Adenocarcinoma 473 (32) 130 (14.9) 44 (36.4) 647 (26.2)
 Adenosquamous carcinoma 34 (2.3) 83 (9.5) 4 (3.3) 121 (4.9)
 Other 5 (0.3) 0 (0) 6 (5) 11 (0.4)
Tumor size reporting†
 Median tumor size, cm (range) 0.9 (0-3.8) 1.5 (1-3) 0.8 (0-3.5) 1.5 (0-3.5)
 Patients with tumors ≤2cm, n (%) 238 (85.3) 52 (36.4) 29 (74.4) 319 (69.2)
 Patients with tumors >2cm, n (%) 41 (14.7) 91 (63.6) 10 (25.6) 142 (30.8)
FIGO stage‡, n (%)
 IA1+LVSI 120 (9.6) 70 (8) 7 (6.1) 197 (8.8)
 IA2 190 (15.2) 130 (14.8) 28 (24.3) 348 (15.5)
 IB1 932 (74.8) 667 (75.8) 78 (67.8) 1677 (74.8)
 IB2 4 (0.3) 11 (1.3) 1 (0.9) 16 (0.7)
 IIA 0 (0) 2 (0.2) 1 (0.9) 3 (0.1)
Median depth of invasion, mm (range) 3.1 (3-12) 3.6 (3.5-6) 5.5 (4-8) 5 (3-12)
Presence of LVSI, n (%) 459 (32.1) 200 (29.4) 19 (31.7) 678 (31.2)
Positive pelvic lymph nodes§, n (%)
 Frozen pathology 6 (1.8) 63 (8.2) 4 (6.6) 73 (6.3)
 Final pathology 32 (3.7) 75 (8.8) 5 (4.6) 112 (6.1)
Positive trachelectomy margin§, n (%)
 Frozen pathology 10 (3.1) 48 (5.9) 10 (10.1) 68 (5.5)
 Final pathology 20 (3.4) 27 (6) 11 (10.9) 58 (5.2)
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*

Some articles included more than one dataset, resulting in 52 datasets from 47 articles.

†

Articles reported tumor size as either exact size or number within a set size range.

‡

1994-2009 FIGO staging systems used. Some staging classifications, for example FIGO IIA tumors, were assigned based on final pathology results.

§

Denominators used for calculating frozen and final pathology percentages differed and were calculated based on whether the study reported frozen and final or just final pathology results.

FIGO, International Federation of Gynecology and Obstetrics; LVSI, lymphovascular space invasion

Median operative time across studies was 226 minutes (min) (range 120-479 min). By route, median operative times were 180 min (range 120-330 min) for vaginal, 240 min (range 132-436 min) for abdominal, and 272 min (range 231-360 min) for laparoscopic radical trachelectomy. Median estimated blood loss (EBL) for all groups was 300 cc (range 23-2510 cc). Median EBL was 254 cc (range 100-486 cc) for vaginal, 322 cc (280-2510 cc) for abdominal, and 63 cc (23-692 cc) for laparoscopic radical trachelectomy. Across interventions, 9% of cases were converted to radical hysterectomy. By route, rates of conversion were 3.9% for vaginal, 12.6% for abdominal, and 11.8% for laparoscopic radical trachelectomy. Reasons cited for conversion included positive lymph node involvement (48.3%) or positive isthmus margins (45%) upon frozen pathology assessment or due to reasons unspecified (6.6%). Details of operative outcomes can be found in Table 2.

Table 2.

Operative, Oncologic, and Pregnancy Outcomes of Women Undergoing Radical Trachelectomy

Outcome Vaginal radical trachelectomy Abdominal radical trachelectomy Laparoscopic radical trachelectomy Total
Number of patients, n 1491 955 120 2566
Median operative time, minutes (range) 180 (120-330) 240 (132-436) 272 (231-360) 226 (120-479)
Median estimated blood loss, cc (range) 254 (100-486) 322 (280-2510) 63 (23-692) 300 (23-2510)
Intraoperative conversion to hysterectomy, n (%) 26 (3.9) 111 (12.6) 14 (11.8) 151 (9)
Receipt of postoperative RT, n (%) 47 (4.4) 42 (5.4) 0 (0) 89 (4.7)
Median follow-up, months (range) 50.9 (9.8-202) 38 (2-66) 25 (3.5-52.8) 48 (2-202)
Median recurrence rate, % (range) 3.8 (0-9.9) 3.3 (0-9.8) 0 (0-25)* 3.3 (0-25)*
Median time to recurrence, months (range) 26.1 (11-44) 26 (12.5-26) 8† 26 (8-44)
Median 5-year recurrence free survival, % (range) 94.4 (88-97.3) 96.3† NR 94.6 (88-97.3)
Median death rate from disease, % (range) 1.7 (0-3) 1.5 (0-1.7) 0 (0-3.7) 1.6 (0-3.7)
Median 5-year overall survival, % (range) 97.4 (95-99) 98.6† NR 97.4 (95-99)
Post-trachelectomy pregnancies, n 177 41 7 225
 Pregnancy rate, % 37.8 10.4 9.2 23.9
 Nonviable delivery/abortion, n (%) 43 (24.3) 10 (24.4) 3 (42.9) 56 (24.9)
 Preterm delivery, n (%) 60 (33.9) 16 (39) 4 (57.1) 80 (35.6)
 Term delivery, n (%) 74 (41.8) 15 (36.6) 0 (0) 89 (39.6)
 Live birth rate‡, % 75.7 75.6 57.1 75.1
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*

The 25% rate was an outlying value from an article reporting on only four patients who underwent radical trachelectomy 24.

†

Reported from only one article in the cohort.

‡

Live births represent term and preterm deliveries.

RT, radiation therapy; NR, not reported in any article within the subgroup

Results of lymph node assessments were reported in 41 of 47 studies. At final pathology, 6.1% (112 of 1835 cases) had positive pelvic lymph node involvement. Rates of pelvic lymph node involvement were 3.7% for vaginal (32 of 870 cases), 8.8% for abdominal (75 of 857 cases), and 4.6% for laparoscopic radical trachelectomy (5 of 108 cases). Trachelectomy margin assessment results were reported in 29 of 47 studies. Positive trachelectomy specimen margin rate across studies was 5.2% (58 of 1123 cases), while positive margin rates were 3.4% for vaginal (20 of 597 cases), 6.5% for abdominal (26 of 400 cases), and 6.7% for laparoscopic radical trachelectomy (6 of 89 cases). Details can be found in Table 1. Postoperative management was described in 40 of 47 studies. Adjuvant radiotherapy with or without chemotherapy was administered to 4.7% (89 of 1903 patients) who underwent radical trachelectomy (excluding conversions to radical hysterectomy). Further details can be found in Table 2.

Reporting of follow-up intervals and recurrence data were the inclusion criteria used during screening, thus these data were available for all articles. Median follow-up time across studies was 48 months (mos) (range 2-202 mos). Sorted by intervention, median follow-up times were 50.9 mos (range 9.8-202 mos) for vaginal, 38 mos (range 2-66 mos) for abdominal, and 25 mos (range 3.5-52.8 mos) for laparoscopic radical trachelectomy. Median reported cancer recurrence rate across studies was 3.3% (range 0-25%; the 25% rate was an outlying value from an article reporting on only four patients who underwent radical trachelectomy24; range excluding this value is 0-9.9%). Median recurrence rates were 3.8% (range 0-9.9%) for vaginal, 3.3% (0-9.8%) for abdominal, and 0% (0-25%) for laparoscopic radical trachelectomy.

Median time to recurrence, reported in 12 of 19 articles with at least one recurrence, was 26 mos (range 8-44 mos) across studies and 26.1 mos (range 11-44 mos) for vaginal, 26 mos (range 12.5-26 mos) for abdominal, and 8 mos (range not available) for laparoscopic radical trachelectomy. Median 5-year recurrence-free survival (RFS), reported in 8 articles, was 94.6% (range 88-97.3%) across studies and 94.4% (range 88-97.3%) for vaginal, 96.3% (reported in one article; range not available) for abdominal, and not reported for laparoscopic radical trachelectomy. Median death rate from disease, reported in 12 of 19 articles with at least one recurrence, was 1.6% (range 0-3.7%) for the entire study and 1.7% (range 0-3%) for vaginal, 1.5% (range 0-1.7%) for abdominal, and 0% (range 0-3.7%) for laparoscopic radical trachelectomy. Median 5-year overall survival (OS), reported in 5 articles, was 97.4% (range 95-99%) across all studies and 97.4% (95-99%) for vaginal, 98.6% (reported in one article; range not available) for abdominal, and not reported for laparoscopic radical trachelectomy. Confirmed with our research statisticians, meta-analysis of the collected data was not possible due to heterogeneity in survival statistics. Details of oncologic outcomes can be found in Table 2. Appendixes 1–3 provide additional detailed descriptions of pathology and oncologic outcomes of articles grouped by vaginal, abdominal, or laparoscopic radical trachelectomy.

Pregnancy outcomes were reported in 28 of 47 articles. Sixteen patients underwent radical trachelectomy with a concurrent pregnancy, 4 (25%) of whom had term deliveries, 7 (43.8%) preterm deliveries, and 5 (31.3%) nonviable births or abortions. There were an additional 225 reported post-trachelectomy pregnancies for 940 patients, or a 23.9% postoperative pregnancy rate. By intervention, pregnancy rates were 37.8% for those who underwent vaginal, 10.4% for abdominal, and 9.2% for laparoscopic radical trachelectomy. These rates account for reported pregnancies within the follow-up periods and do not represent the number of women attempting pregnancy during these timeframes. Of these pregnancies, 75.1% resulted in live births (39.6% term deliveries; 35.6% preterm deliveries). By route, postoperative pregnancies resulted in live births for 75.7% of vaginal, 75.6% for abdominal, and 57.1% for laparoscopic radical trachelectomy. Details of reported pregnancy outcomes can be found in Table 2.

A large proportion of articles met greater than 80% of the NIH tool’s quality assessment items and thus received a rating of “good” (46.8%). A similar proportion received a rating of “fair” (42.6%). The rest were deemed “poor” (10.6%). The most common insufficient measure across all studies (case series and case reports) addressed whether the length of follow-up was adequate and was missed by 26 of 47 screened articles (55.3%). Case series frequently fell short of satisfactorily describing the statistical methods used and clearly defining outcome measures across all study participants, missed by 61.3% and 35.5% of screened case series, respectively. The NIH tool questions with results of articles satisfying each criterion can be found in Table 3. The quality rating results from subjecting each article to the NIH tool can be found in Table 4.

Table 3.

NIH Quality Assessment Tool – Questions and Results

Question Articles satisfying criterion, n (%)
1. Was the study question or objective clearly stated? 42 (89.4)
2. Was the study population clearly and fully described, including a case definition? 44 (93.6)
3. Were the cases consecutive?* 28 (90.3)
4. Were the subjects comparable?* 31 (100)
5. Was the intervention clearly described? 45 (95.7)
6. Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?* 20 (64.5)
7. Was the length of follow-up adequate?† 21 (44.7)
8. Were the statistical methods well-described?* 12 (38.7)
9. Were the results well-described? 36 (76.6)
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*

These questions were not applied to case reports; reported percentages were adjusted accordingly.

†

Three years was considered adequate to satisfy this criterion.

Table 4.

NIH Quality Assessment Tool – Quality Rating Results

Quality rating* Articles meeting specified quality rating, n (%)†
Vaginal radical trachelectomy Abdominal radical trachelectomy Laparoscopic radical trachelectomy Total
Good (≥80%) 10 (47.6) 9 (50) 6 (46.2) 22 (46.8)
Fair (≥50% to 80%) 8 (38.1) 8 (44.4) 5 (38.5) 20 (42.6)
Poor (<50%) 3 (14.3) 1 (5.6) 2 (15.4) 5 (10.6)
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*

Individual scores were calculated based on number of satisfactorily met criteria per article.

†

Some articles included more than one dataset, resulting in 52 datasets from 47 articles, but each article only received one score and rating. This is reflected in the columns broken down by route of surgical approach.

DISCUSSION

Here we present a thorough, up to date systematic review of published data regarding radical trachelectomy for the treatment of early-stage cervical cancer. Summarizing this large body of data distills it into useful information for clinicians and defines the state of the science while identifying gaps in the medical literature. Prior publications are limited to observational research, mainly retrospective case series and case reports, and significant differences exist in the reporting of variables which pose a challenge to the accurate compilation of data and ability to compare them critically. Due to rarity of the procedure, reported cases are frequently part of previously published datasets, which further limits the scope of qualitative data syntheses. Nevertheless, we were able to perform a thorough yet succinct review of the literature and synthesis of available information.

Publication characteristics of the collected studies, such as year of publication and country of case origin, emphasize several important issues. Commonly referenced first years of publication for vaginal, abdominal, and laparoscopic radical trachelectomy are 1994, 1997, and 2005, respectively, though most articles eligible for inclusion in our review are published in the 2010s. This highlights slow patient accrual likely due to rarity of the procedure but also temporal limitations of developing a randomized control trial comparing routes of radical trachelectomy. One potential larger issue is the majority of articles published from countries on the lower end of worldwide cervical cancer incidence.1 Cervical cancer remains a global health concern with barriers to care beyond the scope of this publication, but we continue to lack information regarding treatment outcomes from populations with the highest incidence.

We cannot declare one method of radical trachelectomy more favorable than the other, but we do observe interesting trends in the pooled data. Median operative time is reportedly less for vaginal radical trachelectomy than both the abdominal and laparoscopic routes, while estimated blood loss is lowest for the laparoscopic route. The reported rate of conversion to radical hysterectomy for vaginal radical trachelectomy is lower than abdominal and laparoscopic routes by more than twofold, a statistic supported by lower rates of positive frozen lymph nodes or trachelectomy specimen margins in the vaginal radical trachelectomy group. Median follow-up times by route of intervention drop from vaginal to abdominal to laparoscopic radical trachelectomy, coinciding with and likely reflective of the order in which these surgical methods were reported in the literature. Unsurprisingly, the postoperative pregnancy rate is highest for the vaginal route which is also the group with the longest follow-up period. Reported pregnancy rates across studies are likely lower than actual rates as they only represent pregnancies within the follow-up periods and thus susceptible to reporting bias. Despite differences in pregnancy rates by surgical route, however, live birth rates remain roughly similar across interventions. Overall, outcomes such as recurrence rate, death from disease, and recurrence-free and overall survival, when reported, are favorable. We acknowledge that a small percentage of patients received adjuvant therapy during their course of treatment, however articles were not excluded based on this in an effort to reflect real world outcomes. Any trends should be interpreted with caution as these data are not being directly compared in a meta-analysis, and we cannot determine if the determined values for one group are within or outside the margin of error for another group. The ability to make statistical comparisons will hopefully change over the next several years as follow-up and recurrence data evolves.

We also emphasize that our focus here is only radical trachelectomy for the management of early-stage cervical cancer. Pending select histopathologic parameters including lesion size, depth of invasion, and LVSI status, some patients with small-volume tumors may be safely treated with less-radical, conservative surgical approaches. This is well-established for patients with FIGO stage IA1 tumors without LVSI who are candidates for conservative treatment with cervical cone biopsy alone, ensuring negative margins.25 Recommendations for non-radical treatment of stage IA1 tumors with LVSI, up to select, low-risk stage IB1 tumors, are currently evolving. This generally consists of cervical cone biopsy with pelvic lymph node assessment and is supported by NCCN guidelines3, retrospective publications26–29, and preliminary data from the multicenter, prospective ConCerv trial.30 Results from the currently accruing Gynecologic Oncology Group (GOG) 278 trial, evaluating physical function and quality of life before and after non-radical surgical therapy, will also provide evidence regarding conservative approaches.

In addition to helping understand the quality of data synthesized in this review, the NIH assessment tool highlights specific areas within articles that commonly prevent fulfilling quality rating criteria and identifies details for future authors to consider. Outcome measures should be more clearly outlined along with more thorough descriptions of statistical methods and study results. For any oncologic study, recurrence percentages are increasingly accurate as follow-up times increase. The percentage of studies satisfying this NIH tool criterion is highly variable based on time frame selected. We acknowledge that the majority of studies missed our selected parameter and thus might reflect biased reported recurrence rates. Also, we did not initially exclude case reports from this measure, however as the primary outcome of case reports were not recurrences, it may not reliably apply. When case reports were excluded from being expected to meet this parameter, 18 of 31 articles met qualifications (58%).

Strengths of this study include the systematic approach using a predetermined, published research protocol, adherence to standardized guidelines in reporting systematic reviews, exhaustive literature review with guidance from a medical librarian experienced in systematic review methods, organized screening and data collection process, and use of a published tool to quantitatively assess quality of studies used in the review. Study limitations exist in the ability to synthesize observational data, especially with the paucity of survival outcome reporting. We acknowledge the potential for selection and publication bias within individual reports given the retrospective nature of the studies. By using reported medians as values for all patients within studies when calculating pooled outcomes, dataset inflation could have been introduced, impacting the reliability of the data. The frequent absence of survival outcomes being reported is likely due to study follow-up periods shorter than standard oncology outcome timeframes along with, thankfully, rarity of disease recurrence. This comprehensive collection of radical trachelectomy literature also includes data published before the application of less-radical surgery for select cases of cervical cancer. Therefore, more conservative treatments may have been appropriate for those who underwent radical dissections, in line with the approximate two-thirds of tumors here without LVSI.

Based upon this systematic review, fertility-sparing surgical options for eligible patients with cervical cancer include radical vaginal, abdominal, and laparoscopic trachelectomy. It is not yet known whether true differences exist based on route of radical trachelectomy; however, ongoing research, including the International Radical Trachelectomy Assessment (IRTA) study and future registry trials for which our results provide supplementary supportive evidence, may enable us to better address this concern. Fertility-preserving treatment decisions should continue to be based on careful case selection in line with oncologic and patient-directed goals of care.

Supplementary Material

Supplemental Digital Content_1
Supplemental Digital Content_2

Acknowledgments:

The authors thank Alexia Iasonos, PhD and Qin C. Zhou, MA of the Department of Epidemiology and Biostatistics at Memorial Sloan Kettering Cancer Center, for their research assistance.

Funding: This study was funded in part through the NIH (NCI) Support Grant P30 CA008748 (Dr. Leitao, Dr. Sonoda, Dr. Abu-Rustum, Dr. Mueller).

Financial Disclosure:

Dr. Abu-Rustum reports grants from Stryker (Novadaq), grants from Olympus, grants from GRAIL, outside the submitted work. Dr. Leitao is a consultant for Intuitive Surgical Inc., outside the submitted work. The other authors did not report any potential conflicts of interest.

Footnotes

Systematic Review Registration: PROSPERO, CRD42019132443.

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Supplementary Materials

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NIHMS1589960-supplement-Supplemental_Digital_Content_1.pdf (129.9KB, pdf)
Supplemental Digital Content_2
NIHMS1589960-supplement-Supplemental_Digital_Content_2.pdf (390.7KB, pdf)

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