Pathological Safety Assuring On Abdominal Radical Trachelectomy In Patients With Early Stage Cervical Cancer

Part 1. Comparison of surgical scope between abdominal radical trachelectomy and abdominal radical hysterectomy for early stage cervical cancerObjective:To compare the surgical outcomes for patients with early stage cervical cancer after abdominal radical trachelectomy (ART) and abdominal radical hysterectomy (ARH).Methods:A prospective database of ART and ARH procedures performed in a standardized manner by the same surgical group was analyzed. Between 08/2012 and 08/2013,156 patients who were diagnosed epithelial invasion cervical carcinoma with FIGO stage IA1 lymph-vascular space invasion (LVSI), IA2 and IB1 were selected. Depending on patient’s own surgery aspiration, ART was attempted in 47 patients (30.1%), and ARH was attempted in 109 patients (69.9%). After the ART or ATH surgery, the unfixed parametrial tissue from each specimen was placed and well extended, the parametrial length histological length、uterosacral, vesicouterine and vaginal lengths at 3/6/9/12 o’clock were measured and recorded by the same doctor. Dichotomous groupings were analyzed using the chi-square and Fisher’s exact test, and statistical significance was defined as p< 0.05.Results:The radical trachelectomy group was slightly younger than the radical hysterectomy group, with a median age of 32 years (range:20-41 years) compared with 51 years (range:32-80 years) (p< 0.001). The vast majority of patients in both the ART and ARH groups,37 (72.3%) patients were diagnosed with squamous cell carcinoma versus 79 (72.5%), and 34 (75.6%) vs.90 (75.6%) cases were FIGO stage IB 1. In ART and ARH groups, the median parametrial gross length were 44.08 mm compared with 44.96 mm(p=0.432), the median histological length was 25.74±5.24 mm vs.26.09± 5.113 mm (p=0.361). There was no difference in the medial vesicouterine ligament length (3.85 mm vs.4.01 mm, p=0.647) or the medial uterosacral ligament length (13.30 mm vs.12.88 mm, p=0.605), and the medial vaginal length for each position in the ART group was similar to in the ARH group (p>0.05).Conclusion:Using standardized techniques, ART provides similar surgical and outcomes as ARH.Part 2. Parametrial lymph node identification in patients with early stage cervical cancer.Objective:To compare the parametrial lymph nodes (PMLNs) detection in ART and ARH by three-segment technique, and insure the importance of PMLNs, especially ART patients.Methods:Between 08/2012 and 08/2013,156 patients who were diagnosed epithelial invasion cervical carcinoma with FIGO stage IA1 lymph-vascular space invasion, IA2 and IB 1 were selected. A prospective database of ART and ARH procedures performed in a standardized manner by the same surgical group was analyzed. The three-segment technique was used for the accurate analysis of parametrial lymph nodes (PMLNs), and microscopic examination was used to document the presence and the location of PMLN after specimen handled. PTX+CBP was given to patients with PMLNs metastasis for six cycles. Standard statistical tests were used.Results:Thirty-eight (38/47,80.85%) of the parametrial specimens from the ART group included 86 parametrial nodes, whereas 105 (105/109,96.33%) of the ARH specimens had 341 parametrial lymph nodes detected. Most of the PMLNs were localized to the proximal segment in both the ART and ARH groups (63/86{73.26%} and 222/341{65.10%}). A little PMLNs located in uterosacral, vesicouterine ligament. The median PLMNs were 2(0-8) and 3(0-12) in ART and ARH group, p= 0.004. For patients with negative pelvic lymph nodes (PLNs), the positive rate of PMLNs were 6.67% and 6.06% in the two groups, and for patients with positive PLNs, the positive rate of PMLNs were 100% and 66.67%. During the follow-up in 9.6 and 9.8 months, no patients died or recurred.Conclusion:PMLNs located in parametrial tissue dispersedly, and some of PMLNs may attend by the ascending uterine artery in broad ligament. The three-segment technique could provide a higher detection rate for PMLNs. The positive PMLNs could guide postoperative adjuvant therapy for early stage cervical cancer to reduce the risk of recurrence.Part 3. Surgical margin assuring for abdominal radical trachelectomy specimen in frozen sectionsObjective:To summarize our experience in the frozen sections (FS) assessment of the trachelectomy surgical margin.Methods:All fresh cervical specimen of FIGO stage IA1 with LVSI, IA2 or IB1 patients underwent ART from 01/08/2012 to 01/10/2013 were prospectively collected which were 53 in total. The frozen section (FS) was consistently carried out by a group of gynecologic pathologists according to the protocol described in details in this article after the cervix divided from corpus. If the frozen section presented residual tumor at 10 mm from cervical surgical margin, an additionally excised tissue was taken, and the second transverse section was submitted. When the second transverse section showed tumor infiltration, the patient underwent radical hysterectomy instead. PTX+CBP was given to patients for three to six cycles depending on the final pathological report.Results:A total of 53 patients, were 20 to 41 (median,32) years of age. Of the patients, 20(37.74%) showed no residual lesion; 11(20.75%)had only nonspecific lesion and 22 (41.51%) had grossly visible lesion, and the rate of tumor residual in primary FS was 5.00%,36.36% and 18.19% respectively.9 patients showed the positive cervical margin in primary FS, and 7 patients (77.78%) were saved in the second FS. The operation survival rate arrived 94.34%. Postoperative adjuvant therapy were given in 15 patients, and no dead or recurrence appeared in median follow-up 9.5 month (rang,2 -17 month).Conclusion:Our institutional intraoperative protocol with examining the circumference 10 mm distance from the cervical surgical margin through an en face section is feasible. This method of FS for radical trachelectomy is convenient, less time consuming, easier to popularize; and without residual tumor assuring.