trachelectomy

Trachelectomy, also known as a cervicectomy, refers to surgical resection of the uterine cervix. It may be considered as a fertility-sparing treatment for low-stage cervical cancer.

Although radical hysterectomy is routine for treatment of endometrial and more advanced cervical cancer, uterine-sparing surgery is performed for low-stage cervical malignancy . It may be performed by vaginal, abdominal, laparoscopic, or robotic approaches. The extent of tissue resection varies:

• excisional cone biopsy
  • sometimes considered a form of trachelectomy, it involves removal of the lower portion of the cervix
• simple trachelectomy
  • resection of the majority of cervix except the internal os
  • cerclage may be placed to prevent uterine incompetence
  • may be considered for intraepithelial neoplasia or superficial carcinomas  
• radical trachelectomy
  • resection of the majority of cervix sparing the internal os, as well as a portion of upper vagina, paravaginal (paracolpos) and parametrial tissue
  • cerclage may be placed to prevent uterine incompetence
  • may be preferred for stage IB1 cervical cancer (controversial)  

Formal trachelectomies are usually preceded by diagnostic pelvic lymphadenectomy to assess for disease beyond the cervix that would preclude a fertility sparing approach.

Suggested eligibility criteria for a radical trachelectomy include :

• childbearing age and desire to preserve fertility, without clinical evidence of impaired fertility
• cancer limited to the cervix, stage IB1 or lower
  • by definition, T1b1 tumors must be <2 cm
  • absence of deep stromal invasion
• tumor located ≥1 cm from cervical internal os
• absence of lymphovascular invasion (LVSI+)
• absence of metastatic (pelvic nodal or distant) disease

Certain histologies are considered more aggressive and are generally excluded:

• neuroendocrine, squamous cell, or serous/clear cell adenocarcinoma

Radiographic assessment

MRI

MRI is the modality of choice for assessing anatomy and disease recurrence in patients prior to and following trachelectomy .

General imaging assessment includes :

• with the resection of the cervix, the expected surgical appearance is that of an end-to-end anastomosis between the corpus uteri and the vaginal vault
• appearance of the anastomosis at the neofornix of the vagina can vary. In about half of cases, there can be a posterior extension of the vaginal wall appearing as a neo-posterior vaginal fornix
• artifacts: suture artifacts arise from two sources
  • anastomotic sutures
  • cerclage sutures, which are placed around the corpus uteri to preserve competence during pregnancy
  • these artifacts are most pronounced with fast spin-echo T2-weighted sequences
• vaginal appearances 
  • there can be diffuse wall thickening since a trachelectomy requires the dissection of paravaginal and parametrial tissue in order to mobilize the proximal vagina and cervix prior to resection. This is reported to occur in ~7% of cases and peaking between 3 and 6 months post surgery .

Post-procedural advice and imaging follow-up recommendations

• patients are asked not to become pregnant until 1 year after trachelectomy
• recommendations for follow up imaging are variable
  • some perform 1-year follow up to assess the status of the cervical remnant and the cerclage
  • other recommendations do not suggest reimaging in the absence of symptoms of recurrence

Siehe auch:

• Zervixkarzinom

und weiter:

• clear cell carcinoma of the cervix