Detailed information and a list of references can be found in Chapter 2.4 of the FertiPROTEKT book, "Indications and fertility preservation methods for oncological and non-oncological disorders", which can be downloaded free of charge.
To date, cervical cancer is the second most common cancer in women worldwide. Currently, one in two women is under 35 years of age at initial diagnosis. As a result of good cancer screening programmes, one third of cervical cancers in Europe will currently be diagnosed in the early stage of FIGO I. About 80% of cervical cancer cases are squamous cell carcinomas. A second type, adenocarcinoma, particularly affects young women and this type is more difficult to detect by the screening methods which are available. Adenocarcinoma has a worse prognosis.
The tumour stage is one of the most important parameters for estimating the prognosis in cervical cancer. In early stages, cervical cancer has a 5-year survival rate of approximately 93%. Further clear prognostic and risk factors for cervical cancer are lymph node involvement, tumour grade (i.e., to what degree the tumour tissue differs from normal tissue) and histology. Patients without lymph node involvement have a 5-year survival rate of approximately 90%, whereas proven nodal involvement reduces the survival rate to 20-60%, depending on the location of the affected lymph nodes.
PROBLEMs OF FERTILITY PRESERVATION IN the treatment OF cervical CARCINOMA IN SITU (pre stage)
Surgical treatment of carcinoma of the cervix in situ does not significantly affect fertility. Newer surgical techniques reduce the negative effect on the closure function of the cervix in subsequent pregnancies.
The treatment of cervical can have a significant influence on fertility in many ways.
In early stages of cervical cancer, surgery is possible as a primarily a curative treatment, i.e. curative. The uterus and therefore fertility can only be preserved in early tumour stages up to maximum FIGO IB and a tumour size of<2 cm. At higher stages, the uterus must be removed and pregnancy is no longer possible.
Preservation of the ovaries is aimed for if possible for in cervical cancer. In individual cases, ovarian-preserving surgery can also be performed for adenocarcinoma after a risk assessment (<FIGO IB2).
If combined pelvic radiochemotherapy is necessary, the ovaries should be relocated out of the radiation field. Ovarian tissue can be removed at the same time for storage. The damaging effect of radiotherapy in the pelvic cavity depends on the total dose of irradiation, the calculated local dose to the ovaries and the age of the woman at the time of radiotherapy. The radiation dose in 97.5% of treated women aged 30 years who experienced complete sterilization was 14.3 Gy.
If irradiation of more than 45 Gy impacts the uterus, the radiation-induced changes in the uterine tissue are not compatible with a later pregnancy. Even lower doses may adversely affect a pregnancy. A uterus transplant would then be an experimental approach.
Combined chemoradiotherapy typically consists of platinum-containing regimens for sensitisation. The damaging effect on the ovaries is potentiated by simultaneous irradiation of the pelvis.Bei der kombinierten Radiochemotherapie werden typischerweise zumeist Platin-haltige Schemata zur Sensibilisierung genutzt. Der die Eierstöcke schädigendeEffekt potenziert sich mit der gleichzeitigen Bestrahlung des kleinen Beckens.
Currently, chemotherapy is only used experimentally at higher stages in individual cases to enable the uterus to be preserved. Ovarian tissue can also be removed during the laparoscopy which is performed prior to the start of chemotherapy to remove lymph nodes.
In higher stages, active fertility preservation is not sensible and jeopardizes the chances of cure.
risks of fertility preservation treatment
Metastasis of early cervical cancer to the ovaries is rare and is rather found in higher tumour stages. Nevertheless, there is an increased risk of metastasis to the ovaries in young women with adenocarcinoma, which has already even been described for carcinoma in situ. This must be considered when preserving the ovaries.
The relocation of the ovaries out of the pelvis can also contribute to a reduction in the ovarian reserve as a result of disruption to the blood supply.
practical apprioach if fertility preservation is considered
Fertility-preserving surgery is possible in a patient who wishes to conceive and has newly diagnosed early cervical cancer FIGO IA1 with risk factors or up to IA2 without risk factors. However, the increased risk of relapse in isolated cases must be considered.
Relocation of the ovaries out of the pelvis can be performed before planned pelvic radiotherapy. Ovarian tissue can be simultaneously removed for cryopreservation during this procedure.
Chemotherapy for cervical carcinoma in higher stages to allow fertility preserving surgery is very controversial and should be classified as experimental.