Uterine transposition: A novel option to preserve fertility in patients requiring pelvic chemoradiation

Courtesy: University of Queensland.

Uterine transposition is an interesting and novel technique not ever reported in literature. This is the first case report of uterine transposition and technique published in August issue of Journal Fertility and Sterility.

All gynecologists are familiar with transposing ovaries to preserve fertility and avoid premature menopause in patients who require radiation treatment to the pelvis for cervical cancer.

Dr Reitan Ribeiro from Brazil reports the case of a 26-year-old woman diagnosed with rectal adenocarcinoma located 5 cm from the anal margin. The patient was young and did not have any children and wanted to preserve her fertility.

Dr Ribeiro offered the patient a repositioning of the uterus outside the pelvic cavity called along with the ovaries outside the pelvic cavity, to save them from harm due to pelvic radiation.

The maximum tolerated radiation dose for the ovaries is 15 Gy; for uterus and cervix it is 20 Gy to 30 Gy. But, the radiation dose for curing rectal cancer is significantly higher and is approximately 50 Gy, at which all the pelvic organs will be certainly damaged.

After the radiation treatment was complete the uterus was repositioned back into the pelvic cavity.

The entire procedure was carried out laparoscopically (key hole surgery) without a big abdominal incision. The basis for this procedure is that the blood vessels to the ovaries provide also good blood supply for the uterus at the same time.

The uterus and ovarian functions were preserved as evident by 2 menstrual period that began after 2 weeks of repositioning the uterus back and the cyclic ovarian hormonal variation was maintained at the time of neoadjuvant therapy.

At per speculum examination at 6 weeks the cervix was entirely normal looking and at 18 months follow up the uterus appeared to be normal.

The paper was also presented by Dr. Ribeiro at Society of Gynecologic Oncology 2017Annual Meeting from 10 to 14 March in Washington D.C.

He did acknowledge that further studies are warranted to establish the safety and efficacy of the procedure. The spread of tumor to a location not easily amenable to treatment was a major concern.

Dr Riberio and colleagues have launched a Uterine Transposition: Feasibility Study  and will shortly start recruiting patients.

This prospective nonrandomized multicenter phase I study, will evaluate the feasibility of performing uterine transposition before chemoradiation for rectal cancer and uterine reimplantation after the treatment. 

The authors concluded that, “Uterine transposition might represent a valid option for fertility preservation in women who require pelvic radiotherapy and want to bear children.” 

Related link: Ovarian Transposition: A novel laparoscopic surgical method video by Cleveland Clinics.

https://obgynupdated.blogspot.com/2017/03/ovarian-transposition-novel_17.html

CDC reports a rise in Human papillomavirus(HPV) associated cancers in recent years.

Clinical Pearls:

• HPV associated cancers are on the rise.
• Out of 38,793 HPV-associated cancers diagnosed each year in U.S, nearly 79 % were preventable cancer caused due to HPV strains for which vaccine coverage is available across population.
• Out of all the HPV associated cancer, only cervical cancer is preventable by good screening strategies. No population based screening strategy exist for other HPV associated cancer.

The CDC reported a rise in Human papillomavirus(HPV) associated cancers in recent years’ in its Morbidity and Mortality Weekly Report published on line on July 7, 2016.[1] It is known that HPV is a cause of cervical cancers as well as vulvar, vaginal, oropharyngeal, rectal and anal cancers. 13 known strains of HPV are carcinogenic and persistent infection with these can progress to precancer and cancer.

CDC analyzed the high quality data obtained from population-based cancer registries of National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results program from 2008–2012, covering approximately 99% of US population.

There was an overall increase in HPV-associated cancer from 10.8 per 100,000 persons during 2004–2008 to 11.7 per 100,000 persons during 2008–2012.

 An average of 38,793 HPV-associated cancers were diagnosed each year during the study span of 5 years. Out of which 23,000 were among females and 15,793 among males. Out of 38,793 at least 30,700(79%) can be attributed to HPV.

Notably, of these 24,600 cancers are attributable to HPV types 16 and 18, which are targeted by all current HPV vaccines, and 28,500 are attributable to high-risk HPV types 31, 33, 45, 52, and 58, all included in the 9-valent HPV vaccine. 

The most common HPV associated cancer was cervical cancer (11,771) in females and oropharyngeal squamous cell carcinomas (15,738) mostly in males.

Only cervical cancer can be prevented with regular screening and follow up, no population based screening strategy exist for other HPV associated cancer. The Healthy People 2020 target for cervical screening is 93%, and the2013 statistics report only 80.7% of women undergo complete screening with wide racial and ethnic disparity.

The authors led by Laura J. Viens, MD, of the Division of Cancer Prevention and Control said “HPV vaccination can prevent infection with HPV types that cause cancer at cervical and other sites," including the anus. "Vaccines are available for HPV types 16 and 18, which cause 63% of all HPV-associated cancers in the United States, and for HPV types 31, 33, 45, 52, and 58, which cause an additional 10%." 

The study has very important public health implication that extending coverage to full US population could prevent future HPV-attributable cancers bringing down the incidence dramatically.

The CDC advisory committee recommends routine HPV vaccination (bivalent, quadrivalent, or 9-valent) for females aged 11-12 through 26 years and quadrivalent or 9-valent for males at ages 11 to 12 through 21 for males if they were not previously vaccinated.

"In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer," said Electra Paskett. She is co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer in Columbus.

"Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes -- and we would have a dramatic decrease in HPV-related cancers across the globe," Paskett added.

"Ongoing surveillance for HPV-associated cancers using high-quality population-based registries is needed to monitor trends in cancer incidence that might result from increasing use of HPV vaccines and changes in cervical cancer screening practices," the CDC report concluded.

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[1] https://www.cdc.gov/mmwr/volumes/65/wr/mm6526a1.htm?s_cid=mm6526a1_w