This article was first published in
KKH Special Delivery Mar-Apr 2015 issue.

Thirty-year-old Ms Susan Zhao is believed to be the first patient in a restructured hospital in Singapore to have conceived and delivered a child after undergoing a radical abdominal trachelectomy (RAT) – a fertility-sparing surgical procedure for young patients with early stage cervical cancer.

RAT has been described as a successful fertility-sparing procedure in medical literature for more than a decade, with about 400 reported cases globally.   In Singapore, KK Women’s and Children’s Hospital (KKH) is the main centre that carries out RAT. Since 2010, the hospital has successfully carried out RAT for eight patients diagnosed with early stage cervical cancer.

“While there is no one method that can guarantee successful conception and delivery, Ms Zhao’s successful pregnancy and birth following RAT spells great hope for other young women affected by cervical cancer who wish to have children,” says Dr Timothy Lim, Head and Senior Consultant, Department of Gynaecological Cancer, KKH, who performed Ms Zhao’s surgery.

Ms Zhao was attended by the following team of senior consultants: Dr Timothy Lim, Head and Senior Consultant; and Associate Professor Philip Yam, Senior Consultant, both from the Department of Gynaecological Cancer; and Adjunct Professor George SH Yeo, Chief of Obstetric, Head and Senior Consultant, Department of Maternal Fetal Medicine and Obstetric Ultrasound and Prenatal Diagnosis Unit, KKH.

First successful birth after radical abdominal trachelectomy

Ms Susan Zhao was diagnosed with early cervical cancer in 2011, after seeking medical evaluation while trying to conceive.   Health screening results revealed the presence of human papillomavirus (HPV) at the neck of her womb – also known as the cervix.

Ms Zhao underwent a cone biopsy at KKH, where a cylindrical sample of cervical tissue was obtained and sent for laboratory testing.   Test results confirmed the presence of early stage cervical cancer, and Ms Zhao was referred to the Gynaecological Cancer Centre at KKH for further assessment and management of her condition.

During discussions with her multidisciplinary care team, Ms Zhao expressed her desire for fertility preservation, as she wished to have a child.  Magnetic resonance imaging scans indicated that the cancer had not spread to Ms Zhao’s lymph nodes.   Thus the care team proceeded to remove the cancer while preserving her womb, through a fertility-sparing surgical technique known as radical abdominal trachelectomy, or RAT.

In 2012, a surgical team performed a RAT to remove Ms Zhao’s cervix, together with surrounding connective tissue and the upper portion of the vagina.   Post-surgery, she was closely monitored for a year, before being given a clean bill of health and encouraged to try to conceive.

Ms Zhao conceived naturally in 2013, but had a miscarriage when she was four months pregnant.   After a six-month rest following her miscarriage, she became pregnant again.   A cervical cerclage, also known as a cervical stitch, was placed during her second trimester of pregnancy, to support her severely shortened cervix.   In 2014, Ms Zhao delivered a healthy child by Caesarean section, and remains cancer-free.

Fertility-sparing intervention for cervical cancer

Cervical cancer is the fifth most common cancer in Singapore – approximately 200 to 250 women are diagnosed with cervical cancer every year.   Almost half of these women are diagnosed in stage I, ten percent of whom are young women aged less than 35 years.

RAT is developed as a form of fertility-sparing surgery for young patients with early stage cervical cancer.   The procedure involves the removal of the cervix, the surrounding parametrial tissue and the upper portion of the vagina, as well as the pelvic lymph nodes, but sparing the uterus and the ovaries.

However, only about five to ten percent of women with cervical cancer are eligible for RAT. Factors considered conducive for RAT include:
• Patient should be less than 40 years
• Cancer should be at an early stage, i.e. stage IA2 - IB1
• No evidence of pelvic lymph node involvement or spread of cancer
• Tumour(s) should be smaller than two centimetres in diameter

The gynaecological oncology team at KKH manages about 150 patients with cervical cancer every year, accounting for about two-thirds of patients with cervical cancer in Singapore.

Regular screening aids early detection of cancer

The pap smear test helps to detect abnormal cell changes in the cervix early, and allow for more effective treatment and intervention against cervical cancer.   Women aged
25 years and above who have had sex, or who are sexually active, are strongly recommended to undergo a pap smear test every three years.

Diagram: The intent of RAT is to resect the cervix, upper 1–2 cm of the vagina, parametrium, and paracolpos (region indicated by a white square) but sparing the uterine corpus.