Fertility-sparing Treatments For Early-stage Cervical Adenocarcinoma: A Meta-analysis

Objective:This study analysed recurrence and survival of conization and hysterectomy,residual lesions and pregnancy outcomes of conization in stage IA cervical adenocarcinoma to assess the safety and effectiveness of the conization and provide more choices for patients with strong willing of fertility preservation.Method:Literatures of stage IA cervical adenocarcinoma were searched in Pubmed,Medline,the Cochrane Library,Embase,CNKI,Wanfang Data,CBM,etc.Literatures searched were published during January 1995 to December 2020.Related books and periodicals of Jilin University Library were searched by hand retrival.Inclusion criteriaes were as follows: ⑴ Objects of study: All cases were pathologically diagnosed as cervical adenocarcinoma,primary tumor,FIGO stage IA(FIGO 2009 staging system);⑵ Conization was performed in the intervention group,and hysterectomy was performed in the control group,with or withnot pelvic lymphadenectomy;⑶ Random/non-randomized controlled trials,case-control studies,cohort studies,etc;⑷ Main Observed Indexes: The recurrence rate and survival rate of the conization group and the hysterectomy group;The pregnancy outcomes(including live birth rate,abortion rate and pregnancy rate)of the conization group;The positive margins and the residual lesions in the conization group;⑸Literatures published from January 1995 to December 2020,without restriction on the languages;⑹ Sample size ≥ 5 cases;⑺ The original data is complete.The literatures were strictly screened.NOS Scale was used to assess the quality of the literatures.The recurrence rate and OS rate of the conization group compared with the hysterectomy group were analyzed by risk ratio(RR)and 95% credibility interval(CI).Pregnancy outcomes(including live birth rate,abortion rate,pregnancy rate,etc.),marginal positive rate,lesion residual rate,lesion residual/marginal positive ratio,and lesion residual/marginal negative ratio of conization group were analyzed by single group rate Meta-analysis,and forest maps were drawn.Funnel plots were used for Bias analysis.The stability of the results was tested by sensitivity analysis.Meta-analysis was performed by Rev Man 5.3.Results:In this study,a total of 12 English literatures were included,all of which were retrospective cohort studies.A total of 1331 patients were included.286 patients were treated with conization and 1045 patients were treated with hysterectomy.The results showed as follows: ⑴ The recurrence rate of patients with stage IA cervical adenocarcinoma undergoing conization compared with hysterectomy(P = 0.71>0.05,RR=1.30,95%CI:0.33-5.16)and OS rate(P = 0.36>0.05,RR=1.01,95%CI:0.99-1.03)were not statistically significant;Subgroup analysis showed that the recurrence rate of patients with stage IA1 cervical adenocarcinoma undergoing conization compared with hysterectomy(P = 0.44>0.05,RR=1.94,95%CI:0.36-10.62)and IA2(P = 0.94>0.05,RR=0.89,95%CI : 0.05-16.36)were not statistically significant,the OS rate of patients with stage IA1 cervical adenocarcinoma undergoing conization compared with hysterectomy(P = 0.32>0.05,RR=1.01,95%CI:0.99-1.04)and IA2(P = 0.93>0.05,RR=1.00,95%CI:0.96-1.05)were not statistically significant;⑵ The pregnancy rate of patients with stage IA cervical adenocarcinoma treated conization was 50%(95%CI,37.1%-62.8%),the abortion rate was 19.4%(95%CI,10.2%-36.4%)and the live birth rate was 72.3%(95%CI,55.8%-84.4%);⑶ The marginal positive rate was 32.0%(95%CI,14.5%-56.1%).Subgroup analysis showed that the marginal positive rate in CKC,LEEP and LC were34.6%(95%CI,8.3%-75.7%),32.0%(95%CI,16.0%-53.7%)and 24.8%(95%CI,6.5%-61.8%),there were not statistically significant in three groups.The lesion residual rate was 38.3%(95%CI,18.0%-63.6%).The subgroup analysis showed that the lesion residual rate of CKC was 54.3%(95%CI,9.1%-67.6%),LEEP was 18.7%(95%CI,7.4%-40.8%),and LC were not residual,the rate of CKC group was higher than the others.The lesion residual/marginal positive ratio was 44.8%(95%CI,19.4%-73.3%),and the lesion residual/marginal negative ratio was 31.5%(95%CI,11.5%-61.8%).The incidence of LVSI in stage IA cervical adenocarcinoma was 7.4%(95%CI,4.8%-12.3%).The subgroup analysis showed that the incidence of LVSI in stage IA1 cervical adenocarcinoma was 5.7%(95%CI,2.9%-10.7%)and in stage IA2 was 16.0%(95%CI,8.3%-30.1%).The rate of IA2 was higher than IA1.Conclusions:⑴ Compared with radical surgerys,conization doesn’t increase the risk of the recurrence of stage IA1 cervical adenocarcinoma.For stage IA2,conization is relatively safe,but there were fewer cases included and further evaluation is needed.⑵ Conization can effectively preserve fertility in patients with stage IA cervical adenocarcinoma.