Neoadjuvant chemotherapy in fertility-sparing management of FIGO 2018 stage IB2 cervical cancer

Currently, the standard management of patients with FIGO 2018 stage IB2 cervical cancer consists of open radical hysterectomy, with pre-operative utero-vaginal brachytherapy in certain settings. However, nearly 40% of cervical cancers occur in women of childbearing age. Fertility preservation therefore represents a challenge in these patients. Two options are then considered: abdominal radical trachelectomy (by open, laparoscopic, and robot-assisted approach) or neoadjuvant chemotherapy followed by conservative surgery. In our institution, neoadjuvant chemotherapy was proposed only in patients with FIGO 2018 stage IB2 <30 mm (on the basis of initial conization if done outside our institution or combining clinical examination and MRI). All these potential indications were thoroughly evaluated in a multidisciplinary treatment meeting. Even in a similar selected group of patients with ‘better’ prognostic factors (smaller size of stage IB2 lesion and negative node) our results were slightly disappointing: two patients had residual disease in the cervix (one requiring an adjuvant hysterectomy and the other brachytherapy, although this was refused by the patient). Lastly, fertility-sparing surgery was successful only in two cases and no pregnancies were observed. These results are in line with recent publications reporting failure or recurrences after neoadjuvant chemotherapy.16 17 As we await the results of the two ongoing prospective studies on the role of neoadjuvant chemotherapy in the setting of fertility preservation, the uncertainties concerning oncologic safety should be discussed with the patient and balanced with the risk of loss of fertility with the option of radical trachelectomy.