Preserving Fertility During Pelvic Radiation: A Multidisciplinary Surgical Approach

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a Medical Oncologist and Co-Director of the Sarcoma Program at Cleveland Clinic. Today we're exploring a novel surgical approach that has expanded what's possible in fertility preservation for cancer patients called uterine transposition. Recently performed at Cleveland Clinic for a young patient with rectal cancer, this technique aims to preserve not only ovarian function, but the uterus itself potentially allowing patients to carry a pregnancy after treatment. I'm happy to be joined by doctors Robert DeBernardo and Johanna Kelley. Dr. DeBernardo is the section head for gynecologic oncology here at Cleveland Clinic, and Dr. Kelley is a gynecologic oncologist in that group. So welcome.

Robert DeBernardo, MD: Thank you.

Johanna Kelley, MD: Thank you for having us.

Dale Shepard, MD, PhD: So to start, we'll start with you. Rob, give us a little idea what you do here at the Cleveland Clinic.

Robert DeBernardo, MD: So I'm the section head of gyn oncology. So mostly do clinical work primarily. We have quite a few research protocols. We have a couple of translational labs. So I head this section of people that are a whole lot smarter and more talented than me. That's basically my role.

Dale Shepard, MD, PhD: I think he's probably being humble. I don't know. So Johanna, what do you do?

Johanna Kelley, MD: Just a little.

Dale Shepard, MD, PhD: Yeah. Yeah. No, I think I know better.

Johanna Kelley, MD: Yeah. I was fortunate enough to come here for fellowship and train under Dr. DeBernardo and then stay on as staff. And I love my job here. I get to do a range of clinical care, including chemotherapy, surgery, surveillance care for patients, and then be involved in the research side and innovation as well. I think one of the best parts of the clinic is the multidisciplinary collaboration that we have here. And so I help lead our gyn oncology tumor board and our multivisceral cancer resection team. And then I was fortunate to be brought on to assist with the uterine transposition program as well.

Dale Shepard, MD, PhD: Very good. So we actually had a podcast episode with Dr. Christianson about two years ago that talked a little bit about setting up a program for this. And that episode's still around if people want to go back and listen. But we're going to talk about really a patient case here and really the fruition of those efforts. So maybe tell us a little bit about the case and...

Robert DeBernardo, MD: Sure. Mindy, when she came to join us, she and I talked about developing this program, what it would take. And so we have a cadaver lab here, so we've done a few of them in the cadaver lab. And we've been looking for patients essentially ever since. And so this young woman presented, she's 30, has not had children, sort of presented with a typical rectal bleeding and was ultimately found to have a cancer. She had neoadjuvant chemo with not a terrific response. And so the next step in her therapy obviously would be pelvic radiation. She got in to see us and we talked to her about this as an option and she was all in. So that's sort of really the crux of it. So we know we wanted to potentially spare her anus and so the pre-op radiation was the way that we were going to go, but that would obviously render her infertile.

Dale Shepard, MD, PhD: So people might be familiar with ovarian transposition. So give us a little bit of an idea. Uterine transposition, what exactly are we talking about here?

Johanna Kelley, MD: Yeah. So this is an exciting new approach where rather than leaving the uterus and cervix in the pelvis, we are able to completely mobilize everything and detach the cervix from the upper vagina so that we can move the uterus, cervix, fallopian tubes, and ovaries all together into the upper abdomen to be out of the radiation field.

Dale Shepard, MD, PhD: And so why is that important? People might be listening in, a lot of different backgrounds. Why is this important?

Robert DeBernardo, MD: Sure. So a few things. So first of all, radiation is toxic to the ovary. So one dose of radiation and we'll have ovarian failure. Pelvic radiation for rectal cancer would render the uterus sterile. That endometrial cavity would no longer be able to have an implantation of a pregnancy. So the damage that we do to treat her cancer would render her infertile. So ovaries get their blood supply fairly high off the aorta by the renal blood supply. So by mobilizing all that, we can perfuse the uterus and the cervix through those vessels. So we very simply do a dissection where it's essentially a hysterectomy where we leave everything connected by the gonadal vessels, and then we can bring it up.

And in this case, we were able to get the cervix up to her xiphoid, which we didn't ultimately deliver the cervix, but we deliver it like a stoma, like a colostomy. So we delivered it a few finger bests above the belly button, and that was far enough outside the pelvic radiated area. And during the procedure, we also used fluoroscopy to make sure that, oh, once we de-insufflated, that those ovaries and that uterus were far out of the field.

Dale Shepard, MD, PhD: And then you mentioned something about the stoma, about delivering the cervix. What does that mean?

Johanna Kelley, MD: Yeah. So-

Dale Shepard, MD, PhD: Again, for us non-surgeons, you got a shop talk. Yeah. I can deliver the cervix.

Johanna Kelley, MD: So for this case, we carefully chose our port placements and did this procedure laparoscopically. So the patient had a very quick recovery, and we were able to mobilize everything and ultimately bring the cervix through the abdominal wall so that the cervix was sitting attached to the skin of the abdominal wall so that any blood or mucus that might come out of the cervix would not then go on to form intra-abdominal adhesions.

Dale Shepard, MD, PhD: Okay. Very good. You mentioned at the very beginning, you talked about how finding a patient. What makes for a good patient? Clearly somebody's going to get pelvic radiation, but outside of that, what makes for a good patient?

Robert DeBernardo, MD: Patients that are young and interested in fertility, somebody with a pelvic malignancy. Rectal cancer seems the obvious choice, especially with increasing numbers of young people with this cancer, but potentially other pelvic cancers that require radiation. I think somebody that had a very large BMI, it might be more challenging, although I wouldn't necessarily take that off the table. And somebody whose cancer prognosis is reasonably good. One of the things that I think was important when Mindy and I first started speaking about this and when Joey and Michelle, one of our other partners is involved, is we need to get these people in quickly. And this was the first procedure done laparoscopically, which is important because we need to get these people treatment for their cancer. So this whole process delayed her therapy about three weeks. So that's in the grand scheme of things, not terrible.

Dale Shepard, MD, PhD: So it was about three weeks from when she had surgery until she could start the radiation?

Robert DeBernardo, MD: No, three weeks from when she met us until she started radiation. So she met us. She had actually stimulation of her ovaries to harvest eggs in case we had an issue. She had surgery. Two weeks later, she started radiation after her surgery.

Dale Shepard, MD, PhD: So I guess remind us traditionally what would be considered a way that people could have fertility preservation. So this sounds like a really good way to kind of quickly get everything out of the way, do the treatment. What did we have to do in the past?

Johanna Kelley, MD: Yeah. So in the past, someone would have to undergo ovarian stimulation with egg harvesting and then down the road find a gestational carrier ultimately to carry the pregnancy as the uterus would not be functional in order to yeah, carry a pregnancy to term and deliver a healthy baby.

Robert DeBernardo, MD: The hard part about that, practically speaking, is those services are not typically covered by insurance, so.

Dale Shepard, MD, PhD: And not cheap.

Robert DeBernardo, MD: Exactly. And so what's exciting to me about this approach is the surgery took about two and a half hours. She was really, it was an outpatient surgery. We watched her overnight just because, but her recovery was super quick. So theoretically, we put her uterus already back in her pelvis because she completed her therapy. Theoretically, she can have a child the old-fashioned way. Now we would want her to deliver by C-section, but other than that, she probably won't need reproductive assistance to get pregnant.

Dale Shepard, MD, PhD: Is this something that is covered by insurance?

Robert DeBernardo, MD: So no, but what we've done is we bill for an ovarian transposition and then put some additional codes. So insurance is going to pay for what they pay for, but just like our uterine transplant program here, I mean, it's the right thing to do. And if this becomes what we hope is a new way of offering these young women fertility preservation, then we'll develop codes and it would be a billable procedure.

Dale Shepard, MD, PhD: Yeah. So you mentioned uterine transplant. So remind everyone that might be listening in like transposition versus transplant.

Johanna Kelley, MD: Yeah. So transposition means moving the uterus and cervix with the tubes and ovaries up into the upper abdomen, and then bringing that back down after pelvic radiation is completed with a surgery that can take place at the same as a colorectal resection, which is what we did for this patient. In contrast, uterine transplant is when a patient does not have a functional uterus themselves and therefore receives an organ from another patient and then has to undergo an operation for that, be on immunosuppressive therapies and therefore is much more involved than the procedure and recovery in this situation.

Dale Shepard, MD, PhD: That might be something for someone who previously had say a rectal cancer, got pelvic radiation that damaged the uterus by scarring and things, and then if they wanted to become pregnant, they would need a transplant.

Robert DeBernardo, MD: Potentially. The majority of those transplant patients are patients that were born without a uterus or something along those lines.

Dale Shepard, MD, PhD: What was necessary from a innovation standpoint to do this laparoscopically?

Johanna Kelley, MD: Most of these that have been reported around the country have been performed robotically. However, we do a very large volume of complex laparoscopy here at the clinic. And so we felt comfortable that we could provide this to the patient from a laparoscopic approach rather than robotically. We did take care in terms of our port placement, and we did use a technology called ICG dye, which is something that we also use for sentinel lymph node mapping. And our cancers and other cancers, it's also used to assess perfusion at the time of colorectal reanastomosis. So during this case, we did use the ICG to evaluate the perfusion of the uterus and cervix after we had taken the uterine vessels very low at the level of the cervix. So that was one interesting technology. And then Dr. DeBernardo was able to come up with the idea to use intraoperative x-ray to ensure that the transposed uterus, cervix, tubes, and ovaries would all be completely outside the radiation field when she ultimately went to receive radiation. And you can talk a little more about that.

Robert DeBernardo, MD: Yeah. I mean, so that's, I think, important because why put somebody through an operation with, oh, we deinsufflate and then postoperatively, the organ's still in the pelvis. And we see that sometimes with ovarian transposition if they're not done properly. The other thing I think that was a little different than other published cases, and there've been about two dozen worldwide, is the way we took care of the ovaries. So we delivered the cervix like you would develop a colostomy, which sort of held the uterus in place. And then we kind of took the ovaries instead of tacking them to the abdominal wall, which many people have reported. We sort of tucked them in kind of like a bird closing their wings. And I think that worked actually really nicely for her because when we re-implanted the uterus back, it was relatively easy. We didn't have a lot of things to take down.

Dale Shepard, MD, PhD: Surgeons are surgeons. You always look for some better way to do something. So what did you learn with this procedure that you'd like to maybe modify for future cases?

Robert DeBernardo, MD: So in this case, I would be really excited to reverse this laparoscopically. With this particular patient, she needed an open procedure to deal with her rectal cancer. So reconnecting her was very simple for our standpoint. So we've done a reversal laparoscopically in the lab. That'll be kind of interesting to kind of modify the technique to make that efficient, but I'm confident we can do that. And I guess from my perspective, we do a lot of these rectal surgeries laparoscopically. It's going to be important if this becomes part of our armamentarium, that we can do this laparoscopically because the recovery is so much quicker.

Dale Shepard, MD, PhD: Yeah. Talked about multidisciplinary care, talked about engaging, like making sure things aren't in radiation fields. How does the radiation oncologist become involved in terms of planning before even the surgery? Is there intraoperative sort of assessment? How does that work?

Robert DeBernardo, MD: Yeah, so we had everybody involved, which is what's nice. And when we started talking about this as a program, there are key people in our section, in REI, in radiation oncology, in GI that are hip. So if somebody calls, they're going to get plugged in right away so that we're not waiting three weeks to get them to see somebody and then we got to get a team together. So this happens very quickly. So we had radiation oncology in the room with us, one of the residents that was involved in this patient's care and a staff who was looking at images because they were in clinic, but they were like, "Yep, that looks perfect." And so that was really very nice, to have that level of support.

Dale Shepard, MD, PhD: When we think about this as a technique, how widely adaptable is this to patients as we move forward?

Johanna Kelley, MD: I think that this will be really important going forward. There was recent data that showed up to 10% of colorectal cancers and up to 20% of rectal cancers will be diagnosed in patients under 50 in the next few years. And so I think that for patients who are interested in fertility preservation and young and healthy, that this is a really exciting option for them.

Dale Shepard, MD, PhD: It sounds like through all of the people involved and the need for being done quickly, it's still going to be something for the foreseeable future. It's going to be done at specialty centers.

Robert DeBernardo, MD: Correct. And this patient came from quite a distance, so a lot of her care was done locally. So that was something that is important because people listening to this podcast may say, "Oh my goodness, I have a patient that might be, but we're six hours away." And we can make that happen. I mean, the preoperative chemo. We would prefer to see this patient earlier in the process. We have a patient from Michigan now who's getting chemo, but she's already been seen. She's already on our radar. So if she doesn't have the response we're looking for, she's all plugged in. So I think that's where this is helpful, that people can come, have this done here, and then go back home to finish the rest of their treatment. And again, with a minimally invasive approach, they'll be in town for a few days.

Dale Shepard, MD, PhD: So if somebody is listening and they're interested in having their patient evaluated, how would they go about doing that?

Robert DeBernardo, MD: I think probably the easiest way would be to contact either Dr. Kelley, myself, or Dr. Kuznicki, we're the three gyn oncologists that are doing this, or Mindy Christianson. Contact one of us by phone, by email, and we'll make it all happen. We don't have anything like a specific website or anything right now, but I think that would be the easiest way. One phone call we can chat about the patient. Sure, that sounds like they would be good and we can get everything moving from there.

Dale Shepard, MD, PhD: Perfect. Sounds great. Well, it's certainly a fascinating sort of journey. Talked about this a couple of years ago, how this is all getting set up. Now we have a patient that's been successfully treated, so it's a nice progression here. You guys are making good progress, making an impact. So appreciate you being here.

Robert DeBernardo, MD: Well, thank you for having us. I mean, it's nice to get the word out because this is something that I don't think is on people's radar because it's something that's really relatively new in this space. Hopefully it becomes something that we are seeing more and more of.

Dale Shepard, MD, PhD: Perfect. Thank you.

Robert DeBernardo, MD: Yeah. All right.

Johanna Kelley, MD: Yeah.

Robert DeBernardo, MD: Thanks, Dale.

Johanna Kelley, MD: Thank you.

Dale Shepard, MD, PhD: To make a direct online referral to our Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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