The importance of clearance during surgical excision in pre-invasive and invasive cervical disease with the use of new innovative technologies to aid fertility preservation

Abstract

Background: Cervical cancer is the commonest gynaecological malignancy in women of reproductive-age and early-stage disease can be treated using fertility-sparing techniques although there is a current lack of evidence to suggest which affords the best oncological and reproductive outcomes. Clearance of surgical margins prevents the need for adjuvant chemoradiation and preserves fertility. Rapid Evaporative Ionisation Mass Spectrometry (REIMS) could improve accuracy of excision.

Aims: Explore current UK surgical practice for early-stage cervical cancer (ESCC). Perform a systematic review and meta-analysis of oncological and reproductive outcomes following trachelectomy for ESCC according to surgical technique. Investigate whether REIMS could be used to differentiate between healthy and abnormal cervical tissue. Perform metabolite identification using Mass Spectrometry/Mass Spectrometry (MS/MS).

Results: A survey of UK-based surgeons confirmed a variation in treatment approaches for ESCC. A systematic review and meta-analysis of 71 studies demonstrated 8.17% of trachelectomy specimens had positive margins at final histology. Abdominal radical trachelectomy was associated with better oncological outcomes, and vaginal radical trachelectomy with higher conception rates post-operatively. An analytical model for distinction between healthy, preinvasive and cancerous cervical tissue was developed using REIMS that distinguished between these tissue types with 100% diagnostic accuracy. Significant lipid species responsible for this distinction were identified.

Discussion: These findings suggest establishing supra-regional centres for the treatment of ESCC may optimise outcomes in fertility-sparing treatment. Meta-analysis demonstrated that the surgical approach used during trachelectomy may impact on oncological and fertility outcomes, providing evidence for clinicians to counsel patients requesting a fertility-sparing treatment. REIMS has potential as a clinical tool in cervical cancer surgery and colposcopy for accurate intraoperative tissue analysis and as a bedside tool providing real-time results. This may allow clinicians to perform more accurate procedures and reduce patient anxiety associated with waiting for results and reduce the number of hospital visits