Gynecologic Oncology 131 (2013) 8792

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Gynecologic Oncology
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Abdominal radical trachelectomy: Is it safe for IB1 cervical cancer with tumors 2 cm?
Jin Li a,b, Xiaohua Wu a,b,, Xiaoqiu Li b,c, Xingzhu Ju a,b
a b c

Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, PR China Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai, 200032, PR China

H I G H L I G H T S ART could be a safe fertility-sparing option for selected patients with tumors 2 cm in size. A radical resection of parametrial tissue would be critical to secure oncological safety in patients with tumors 2 cm. The discrepancy between node assessment in frozen sections and the nal pathology is a therapeutic problem and needs further investigation.

a r t i c l e

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a b s t r a c t
Objectives. As abdominal radical trachelectomy (ART) has become a favored fertility-sparing procedure, the relative contraindication of a tumor 2 cm in size has been questioned. The aim of the study was to report the surgical and oncological safety of ART for selected patients with cervical cancer 2 cm in size. Methods. We conducted a retrospective review of a prospectively maintained database of patients undergoing ART at our institution from 04/2004 to 01/2013. The largest tumor dimension was determined by physical exam, MRI or nal pathology. Clinical and pathological data were tabulated. All patients were followed postoperatively. Results. Of the 133 patients who underwent planned ART, 62 (46.6%) had tumors 2 cm in size (24 cm). Forty-six patients were documented by exam or MRI, while 16 were documented by pathology reports. The mean age was 30.4 years, and 42 patients (67.7%) were nulliparous. Fifty (80.7%) had squamous carcinoma, 7 (11.3%) had adenocarcinoma and 5 (8%) had adenosquamous carcinoma. Due to frozen-section results, 6 patients (9.7%) underwent an immediate hysterectomy. Due to high-risk features on nal pathology, 27 patients (43.5%) were treated with adjuvant chemotherapy (n = 20) or chemoradiation (n = 7). In total, 55 (88.7%) of 62 patients with a tumor 2 cm in size preserved their fertility potential. Among these patients, 35 underwent ART without further adjuvant treatment. At a median follow-up of 30.2 months, there were no recurrences. Conclusions. Expanding the ART inclusion criteria to cervical cancers 2 cm in size allows a fertility-sparing procedure in young women who would have otherwise been denied the option with no apparent compromise in oncological outcome. However, this may result in higher rates of conversion to hysterectomy or the need for adjuvant chemotherapy/or chemoradiation. 2013 Elsevier Inc. All rights reserved.

Article history: Received 20 April 2013 Accepted 4 July 2013 Available online 19 July 2013 Keywords: Abdominal radical trachelectomy (ART) Cervical cancer Tumor 2 cm Oncological outcomes

Introduction Women with cervical cancer who have delayed childbearing often have a strong desire for fertility-preserving surgery. Radical

Corresponding author at: Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, 270 DongAn Road, Shanghai, 200032, China. Fax: + 86 21 64220677. E-mail address: docwuxh@hotmail.com (X. Wu). 0090-8258/$ see front matter 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ygyno.2013.07.079

trachelectomy (RT) is a viable option for such patients. This novel fertility-sparing surgery has become widely accepted since it was initially developed in 1987 by the French surgeon Daniel Dargent. For oncological safety, vaginal radical trachelectomy (VRT) is generally limited to cervical cancer with a tumor size less than 2 cm. However, because abdominal radical trachelectomy (ART) can remove a wider portion of parametrial tissue than VRT, it is unclear if it would be safe to expand the ART inclusion criteria to cervical cancer patients with tumors 2 cm in size. The purpose of this article is to report our experience with ART in cervical cancer patients whose tumors are 2 cm in size and to describe the surgical and oncological outcomes.

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J. Li et al. / Gynecologic Oncology 131 (2013) 8792 Table 1 Patient characteristics and summary of surgical results. Number of patients Mean age, years (range) Histology Squamous Adenocarcinoma Adenosquamous Tumor size 2 cm 2 cm tumor size b 3 cm 3 cm tumor size 4 cm Parity Nulliparous One child or more Median operative time, min (range) Median number of lymph node (range) Median measured parametrial length, cm (range) Median blood loss, ml (range) Mean length of postoperative hospital stay, days (range) Medianfollow-up time, months (range) Patients converted to RH or underwent chemotherapy (n = 7) Patients preserved their fertility (n = 55) Complications Transfusion Cervical stenosis requiring neo-cervical dilation Lymphocyst Vesical dysfunction T-IUD withdrawal difculty 62 (55 with preserved fertility) 30.4 (2044) 62 50 (80.7%) 7 (11.3%) 5 (8%) 62 33 (53.2%) 29 (46.8%) 62 42 (67.7%) 20 (32.3%) 132 (98230) 24 (1154) 5.4 (3.2-8.7) 280 (100700) 6.8 (521) 30.2 (2-108) 32.6 (5-69) 29.9 (2-108) 12 (18.5%) 3 (4.8%) 2 (3.2%) 4 (6.5%) 1 (1.6%) 2 (3.2%)

Methods With institutional review board approval, we conducted a retrospective review of a prospectively maintained database of patients undergoing fertility-sparing ART for cervical cancer at our institution from 04/2004 to 01/2013. If patients met institutional eligibility criteria, which were published previously [1], they were considered eligible for ART with a pelvic lymphadenectomy. This surgical procedure was approved by the institutional review board, and all patients who planned to undergo ART provided written informed consent before surgery. A total of 133 cervical cancer patients were identied and entered into the study group. All patients underwent a thorough preoperative physical examination by an attending gynecologic oncologist as well as routine preoperative testing. Histopathology from a biopsy or conization was used for the initial diagnosis and was conrmed prior to proceeding with the surgery. A preoperative MRI was obtained to assess the suitability of patients for ART. The largest tumor dimension was determined by physical exam, preoperative MRI or the nal pathology from the cone/LEEP and trachelectomy. When there exists discrepancy among the 3 methodologies, we usually take the largest size. However, diameters determined by physical exam are uniformly less accurate and objective than those determined by MRI or pathological specimen. Thus, we did not include any patients whose preoperative MRI or pathological exam indicated that tumor diameter was b 2 cm and physical exam indicated tumor 2 cm. A specic description of our experience with ART and the details of the surgical techniques in ART were published previously [1]. All patients were thoroughly counseled regarding the need for adjuvant therapy as well as potential issues with infertility. In most cases, pathological risk factors for recurrence after radical hysterectomy were the basis for recommending adjuvant therapy [2,3]. At our institution, patients who had positive pelvic lymph nodes on nal pathology after ART were recommended to undergo adjuvant radiation with concurrent platinum-based chemotherapy. Patients who had deep stromal inltration (DSI) or lymphovascular space invasion (LVSI) on nal pathology underwent adjuvant chemotherapy; the specic treatment regimens have been published previously [1]. Patient characteristics including age, gravidity and parity were abstracted from the medical records. Additionally, pathological and operative reports were reviewed. Follow-up was obtained from the clinics electronic medical records. Results Between 04/2004 and 01/2013, a total of 133 cervical cancer patients underwent a laparotomy for a planned fertility-sparing abdominal radical trachelectomy and pelvic lymphadenectomy. Of them, 62 patients had a tumor 2 cm in size, and these 62 patients constitute our study group. Forty-six patients had their tumor size documented by a physical exam or MRI, while 16 patients had it documented on a pathology report from a cone/LEEP/trachelectomy or summation of the tumor size from the cone/LEEP and trachelectomy. Among patients whose tumor size was 2 cm, 33 had a tumor b 3 cm in size (23 cm) and 29 had a tumor 3 cm in size (34 cm, see Table 1). Six patients underwent immediate completion of a radical hysterectomy due to unfavorable results from intraoperative frozen sections (4 due to positive pelvic nodes and 2 positive/close margins).To prevent selection bias, we included these six patients in the survival and morbidity analysis. The mean patient age was 30.4 years (range, 2044 years). The tumor histology included: 50 (80.7%) squamous carcinomas, 7 (11.3%) adenocarcinomas and 5 (8%) adenosquamous carcinomas. Forty-two patients (67.7%) were nulliparous at the time of surgery while 20 (32.3%) had one or more children. The median operative time was 132 minutes (range, 98230 min). The median measured parametrial length was 5.4 cm (range, 3.28.7 cm; Fig. 1). The pelvic lymph node count was a

mean of 24 nodes (range, 1154 nodes), and the median blood loss was 280 ml (range, 100700 ml). Three patients (4.8%) required a blood transfusion during the operation. The mean length of postoperative hospital stay was 6.8 days (range, 521 days). Four patients (6.5%) required postoperative ultrasound-guided drainage for infected pelvic lymphocysts. They completely recovered without further sequelae. Cervical stenosis was a unique complication after ART. Two patients (3.2%) in our study had clinically notable cervical stenosis and required neo-cervical dilation. To prevent cervical stenosis, we started to routinely install tailed T-type intrauterine devices (T-IUDs) during the procedure in June 2007. The T-IUD was intended to prevent cervical stenosis by separating the anterior and posterior walls of the uterine cavity as well as the endocervical canal. This device can be easily withdrawn during the follow-up appointment 3 months after surgery. However, two patients (3.23%) had the tails of their IUDs drop out, and they required ultrasound-guided dilation of the neo-cervix to withdraw the IUDs. One patient (1.61%) required reinsertion of a Foley catheter 14 days after the trachelectomy for bladder dysfunction; she regained normal bladder function 21 days after ART without further sequelae. Patients characteristics and a summary of surgical results are listed in Table 1.

Fig. 1. Parametrial tissue is radically dissected in patients with a tumor 2 cm in size by abdominal radical trachelectomy.

J. Li et al. / Gynecologic Oncology 131 (2013) 8792 Table 2 Summary of adjuvant chemotherapy in patients with preserved fertility (no hysterectomy or postoperative radiation). No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Age 29 24 26 31 29 35 38 25 28 36 23 25 27 28 27 30 30 30 29 28 Tumor Size (cm) 2.5 3.0 2.0 2.0 4.0 2.5 2.5 4.0 2.0 2.5 3.0 3.0 2.5 4.0 3.5 2.0 3.0 4.0 2.0 3.0 Histology Squamous Adenocarcinoma Squamous Squamous Adenocarcinoma Squamous Squamous Squamous Squamous Adenosquamous Squamous Squamous Squamous Squamous Squamous Squamous Squamous Squamous Squamous Squamous Risk factor DSI LVSI DSI, LVSI LVSI Single positive pelvic lymph node DSI DSI LVSI LVSI Single positive pelvic lymph node DSI LVSI DSI, LVSI DSI DSI DSI, LVSI DSI DSI DSI LVSI DSI, LVSI LVSI Followup (m) 13.0 14.0 14.0 27.0 4.0 10.0 21.0 20.0 21.0 21.0 18.0 19.0 31.0 31.0 31.0 32.0 44.0 73.0 67.0 108.0 Result NED NED NED NED NED NED NED NED NED NED NED NED NED NED NED NED NED NED NED NED

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them succeeded. One patient delivered by cesarean section at 38 weeks and the other 2 were carried to 8 and 21 weeks. Discussion In current gynecological oncology practice, fertility preservation has become a signicant and meaningful issue when deciding on how to treat stage IA-IB cervical cancer [4]. For the rst time, the 2013 NCCN cervical cancer guidelines separate the treatment of stage I cervical cancer based on the desire for fertility preservation. The guidelines also allow the inclusion of select stage IB1 lesions without a restriction on tumor diameter but with the notation that this approach is most validated in lesions b 2 cm in size [5]. Fertility-preserving trachelectomy for cervical cancer is a relatively new procedure, and thus there is a need for data to be reported, collected, and analyzed [6]. In general, VRT in combination with a laparoscopic pelvic lymphadenectomy is the most common and accepted fertility-sparing procedure for early cervical cancer (b 2 cm in diameter), with over 900 cases reported in the literature [7]. The majority of experience with fertility-sparing in cervical cancer has been with VRTs in tumors less than 2 cm in diameter that are stage IA1-IB1. The suggested criteria for performing VRTs include a tumor size 2 cm, and this has essentially remained unchanged over the past 10 years [810]. Because tumor size (which is likely a surrogate of DSI and LVSI) is the most important risk factor for recurrence, restriction of a fertility-sparing radical trachelectomy to those women with tumors less than 2 cm in diameter has been suggested by Dargent et al. [1113]. Other authors have also reported that fertility-sparing surgery performed in patients with tumors 2 cm in size had an increased risk of recurrence [12,14]. Compared with VRT, ART is practiced by relatively few surgeons but with increasing popularity. However, potential advantages of this procedure include no need for training in radical vaginal and laparoscopic surgery and no costs associated with the laparoscopic equipment. Gynecologic oncologists are more familiar with ART because it is similar to an abdominal radical hysterectomy with the exception that the uterus is not removed. ART, a type C1 resection, can remove a wider segment of parametrial tissue than VRT, a type B resection. This procedure appears to be equivalent to the traditional Wertheim procedure (Type C1) in terms of the extent of paracervical resection and provides a standard radical resection of the parametria. Thus, several investigators have suggested that the restriction of fertility-sparing trachelectomy to patients with tumors less than 2 cm in size may not be applicable when the ART is utilized [15]. However, this is currently a controversial issue. At the time of this report, there is no published research specically evaluating the oncological safety of performing ART in tumors 2 cm in size. To our

NED: no evidence of disease; DSI: deep stromal inltration; LVSI: lymphovascular space invasion. Two patients were found to have positive pelvic lymph nodes on nal pathology. They refused to accept adjuvant chemoradiation and only underwent adjuvant chemotherapy.

Six patients (9.7%) who underwent immediate conversion to a radical hysterectomy accepted adjuvant chemoradiation and remain without evidence of disease to date. Among the 56 patients who were managed with ART, 3 patients (4.8%) were found to have positive pelvic lymph nodes on nal pathology. One was treated with adjuvant radiation and concurrent platinum-based chemotherapy, which resulted in the loss of ovarian function. The other two patients refused radiation and only underwent adjuvant chemotherapy. Due to unfavorable pathological ndings on the nal pathological reports, twenty patients (32.3%) underwent adjuvant chemotherapy after ART. Detailed information about these patients is listed in Table 2. In total, 55 (88.7%) of 62 patients with a tumor 2 cm in size preserved their fertility potential (no hysterectomy or postoperative chemoradiation). Speci c characteristics of patients who failed to preserve their fertility are listed in Table 3. With a median follow-up of 30.2 months (range, 2108 months), there are no recurrences to date. In 55 patients whose tumor was 2 cm and preserved their fertility, only 9 patients (9/55, 16%) attempted to conceive and 3 (3/9, 33%) of
Table 3 Patients with a failure to preserve fertility potential. No. 1 2 3 4 5 6 7 Age 30 31 44 26 20 23 27 Histology Squamous Squamous Squamous Squamous Squamous Squamous Squamous Tumor size (cm) 3 4 2.5 2.5 3 2.5 2 Pathologic ndings LN (3/23+); 2/3 cervical stromal invasion LVSI

Treatment RH + PLA +Adjuvant chemoradiation RH + PLA +Adjuvant chemoradiation RH + PLA +Adjuvant chemoradiation RH + PLA +Adjuvant chemoradiation RH + PLA +Adjuvant chemoradiation RH + PLA +Adjuvant chemoradiation ART + PLA +Adjuvant chemoradiation

Follow-up (m) 7 5 31 44 67 5 69

Results Alive with no evidence of disease Alive with no evidence of disease Alive with no evidence of disease Alive with no evidence of disease Alive with no evidence of disease Alive with no evidence of disease Alive with no evidence of disease

LN (3/30+); full cervical stromal invasion; Lymphovascular invasion; Endocervical canal involvement; Deep cervical stromal invasion, Single positive pelvic lymph node Lymphovascular invasion, Two positive pelvic lymph nodes Upper endocervical canal involvement; 2/3 cervical stromal invasion; Upper endocervical canal involvement; Lymphovascular invasion LN (1/19+); full cervical stromal invasion; Lymphovascular invasion

RH = radical hysterectomy; PLA = pelvic lymphadenectomy; ART = abdominal radical trachelectomy. This patient had negative lymph nodes on frozen section evaluation but was found to have positive pelvic lymph nodes on nal pathology.

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knowledge, our study, with 62 cervical cancer patients with tumors 2 cm in size, is the largest series to date describing the surgical and oncological outcomes of ART in such patients. Our aim is not to inuence other gynecologic oncologists, but to report our experience and describe our thoughts on how ART may be used for fertility-sparing treatment in the future. Oncological safety: literature review In 2011, Rob et al. [16] reviewed the performance of ART in IB1 tumors larger than 2 cm in size. There was a higher risk of extrauterine spread, and the risk of recurrence was signicantly higher. However, their review mainly discussed results from 3 papers. One of the 3 papers was a large series published by Nishio et al. in 2009 [17] In this study, 5 of 13 cervical cancer patients who had a tumor 2 cm in size and were treated with ART had a recurrence. However, the other two authors, Cibula and Ungar, reported that a total of 12 patients with tumors 2 cm in size underwent ART, and none of them had a recurrence. Although the oncological outcomes are considered satisfactory, these two studies are relatively old, and the adjuvant therapy may have been variable [1820]. In 2010, Kim et al. [21] from Korea reported their ART experience. One of 8 cervical cancer patients whose tumor measured 2 cm had a recurrence. With a recurrence rate of 12.5%, this series has its limitations, mainly as a result of the small size of the data set. In 2012, Wethington et al. reported an international series on ART [22]. One hundred one patients were planned for fertility-sparing ART and resulted in 28 pregnancies. However, the authors did not mention how many patients had tumor 2 cm in that series. Patient characteristics and oncological outcomes reported in these 5 papers are briey listed in Table 4. We do recognize the limitations of assessing ART in our series given the short follow-up time. However, considering that in the study of Nishio et al., ve of 6 recurrences developed within 18 months, we believe that our results, which show no recurrences at a median follow-up of 30.2 months, could, to some degree, prove the oncological safety of performing ART in patients with tumors 2 cm in size. Extent of parametrial resection Existing research shows that a larger tumor size in cervical cancer is associated with parametrial involvement [23,24]. In order not to compromise oncological outcomes, sufcient parametrial tissue should be resected in patients with tumors 2 cm in size. ART is a safe option for achieving an adequate resection of parametrial, sacrouterine, vesicocervical and pelvic lymphatic tissue. In our study, the median measured parametrial length was 5.4 cm. A comparison of surgical and pathological
Table 4 Patient characteristics and oncological outcomes of ART in 5 series. Nishio Location Period Planned ART, n Patients with spared fertility, n (%) LNM (%) LVSI (%) Average age, years (range) Histology SCC (%) AC (%) Other (%) Size b 2 cm/recurrence N 2 cm/recurrence Recurrences Tokyo, Japan 20022008 71 61 (85.9) 15/71 (21.1) 31/71 (43.7) 33 (2644) 58 (95.1) 2 (3.3) 1 (1.6) 1/48 5/13 6/61 (9.8) Cibula Prague, Czech Republic 20012008 24 17 (70.8) 4/24 (16.7) 2/24 (8.3) 32.4 (2337) 14 (58) 10 (42) 0 1/14 0/3 1/17 (5.9) Ungar

outcomes between 28 patients with VRT and 15 patients with ART was completed by Einstein et al. [25] for patients with stage IB1 cervical cancers. The median measured parametrial length in the VRT group was 1.45 cm versus 3.97 cm in the ART group (p b 0.0001). Although it seemed we had achieved a more extensive parametrial dissection in our study, it is difcult to tell whether this is an advantage of ART. This may simply reect the surgeon's decision to perform a more radical excision because more patients with bulky tumors were included in this study. However, we believe a radical resection of parametrial tissue is vital to achieve zero recurrence. Hysterectomy conversion and adjuvant therapy Broadening selection criteria to 4 cm would lead to an inherently higher risk of conversion to hysterectomy or the need for additional therapy. In this series, 7 (11.3%) of 62 patients ultimately received either an RH (n = 6) or adjuvant chemoradiation post-trachelectomy (n = 1) due to high-risk pathological features, most often positive lymph nodes. In total, 55 patients (88.7%) with a tumor 2 cm in size had preserved fertility potential (no hysterectomy or postoperative chemoradiation). Among them, 35 patients underwent ART without further adjuvant treatment. These data are comparable to the literature. In a review, Rob et al. [26] showed that ART was planned in 207 women, and fertility was spared in 174 patients (84%). In our study, 20 (36.4%) of 55 patients who had preserved fertility potential underwent adjuvant chemotherapy after ART due to unfavorable pathological ndings. LVSI was detected in 11 patients (11/55, 20%). In the literature, the rate of adjuvant therapy is reported to be 9%32% [19,27]. Because the inherent risk of conversion to hysterectomy or the need for additional therapy was high, all patients should be fully informed about all alternative choices before the surgery, and the consent must include information about the risk of infertility. Discrepancy between frozen sections and nal pathology In this study, there were 3 cases where there was a discrepancy between the assessment of pelvic lymph nodes in frozen sections and the nal pathology. In our practice, removed lymph nodes are submitted for frozen section evaluation through sampling. In other centers, where serial frozen sections are used, the safety of fertility-sparing trachelectomy would be increased. However, micrometastasis (lesions less than 2 mm in size) or isolated tumor cells, which could be detected on nal histopathology, may not be diagnosed intraoperatively. This situation is a therapeutic problem. In this situation, patients in our study were told of all viable alternatives before surgery, and informed consent was obtained. Although we recommended adjuvant chemoradiation to

Kim Seoul, Korea 20042009 32 27 (84.3) 4/32 (12.5) 4/32 (12.5) 29 (2237) 20 (74.1) 6 (22.2) 1 (3.7) 0/19 1/8 1/27 (3.7)

Wethington Prague, Czech Republic/ Boston, USA/NY, USA 19992011 101 70 (69) 19/101 (18.8) 47/101 (47) 31 (1943) 40 (40) 54 (53) 7 (7) 4/70 (5.7)

Total

Budapest, Hungary/London, UK/NY, USA 19972002 33 30 (90.9) 2/33 (6.1) 8/33 (24.2) 30.5 (2337) 26 (86.7) 1 (3.3) 3 (10) 0/21 0/9 0/30 (0)

261 205 (78.5) 44/261 () 45/160 (16.9)

158 (65) 73 (30) 12(5) 2/126 (1.6%) 6/33 (18.2%) 12/215 (5.6)

LNM: lymph node metastasis; LVSI: lymphovascular space invasion; SCC: squamous cell carcinoma; AC: adenocarcinoma.

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patients with positive nodes on nal pathology, some patients were more critical of the treatment modality and declined adjuvant therapy. Among the 3 patients in our study, 2 patients preferred adjuvant chemotherapy, which provides a chance for pregnancy. They are alive without a recurrence after 19 and 4 months of follow-up. In the literature, Marchiole et al. [28] reported three patients with lymph nodes micrometastasis who refused adjuvant chemoradiation therapy and in whom recurrences were not diagnosed. In the series by Hertel et al. [13], four patients had positive nodes on nal pathology despite negative frozen sections, but all four refused adjuvant radiation therapy. They accepted adjuvant chemotherapy, and all were reported to be alive without a recurrence. Although oncological results in these cases are promising, the long-term results of adjuvant chemotherapy in node-positive patients after ART are still unclear. It should be emphasized that the classical treatment is still adjuvant chemoradiation or radical hysterectomy. To date, there is no published randomized study that compares the different methods of adjuvant treatment. Whether adjuvant chemotherapy can be used instead of chemoradiation is largely unknown. The role of adjuvant therapy in node-positive post-ART patients deserves further investigation. The role of ART in future fertility-sparing procedures We are aware that new trends are emerging in the conservative management of early stage cervical cancer. There is a role for less radical surgery (simple trachelectomy or large cone biopsy) in node-negative patients with small tumors and less than 1 cm of stromal inltration. Several studies have shown that the parametrial involvement in such patients is extremely rare, and thus less radical surgery without the resection of paracervical tissue was supported [23,2933]. Published oncological results of the less radical surgery were good [34]. For bulky cervical cancer, some centers use neoadjuvant chemotherapy with the aim of down-staging the disease before radical trachelectomy [3537].The idea underlying neoadjuvant chemotherapy is to reduce the size of the cervical tumor to preserve fertility. Although the preliminary results are promising, neoadjuvant chemotherapy combined with fertility-sparing surgery is an experimental concept that requires prospective multicenter studies in the future, especially concerning long-term oncological ndings. We believe that ART is a safer option with regard to tumors 2 cm in size. The extent of such tumors requires a thorough type C1 resection of the parametria that may not be achieved by the traditional VRT, a type B resection. Our study proved that expanding the ART inclusion criteria to cervical cancer patients with tumors 2 cm in size allows a fertility-sparing procedure in young women who would have otherwise been denied the option with no apparent compromise in oncological outcomes. In the future, the decision to pursue a conservative operation for early stage cervical cancer should be individually tailored. For patients with small tumors and few risk factors (e.g., DSI and LVSI), a less radical surgery or vaginal procedure could be a good choice because such procedures implies less disruption of innervations of the uterus end tube. With extremely promising oncological results, ART seems to be a reasonable option for selected patients with tumors 2 cm in size. However, the choice to pursue personalized fertility-sparing surgery should be based on the eligibility criteria, the experience of the surgeons at that institution and the risk of recurrence. The extent of surgical therapy and subsequent adjuvant therapy should be balanced between the patients desire to maintain their fertility and the presence of adverse prognostic variables. Compared with data in literature, we had less favorable obstetrical outcome. This may relate to more radical resection of this surgical procedure, or compromised ovarian function caused by postoperative chemotherapy. Factors that affect patients obstetric outcome are complicated. Our preliminary study showed that in addition to surgery

and chemotherapy, social, familial and physical factors could also greatly inuence the obstetric outcome [1]. Obstetrical outcomes for patients with stage IB1 2- to 4-cm lesions who undergo a successful ART will require long-term follow-up data. We are now conducting an ongoing study to further investigate factors that inuence the obstetrical outcome.
Conict of interest statement The authors have no conicts of interest to declare.

Acknowledgments This research is supported by the Supporting Program for Appropriate Technology of the Shanghai Health Bureau (SHDC12012215). References
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