The Silva pattern-based classification and oncological outcomes in women undergoing fertility-sparing surgery for early-stage cervical cancer.

Objective: To explore the association between Silva pattern-based classification, lymphovascular invasion, and oncological outcomes in women undergoing fertility-sparing surgery for cervical cancer.

Methods: Retrospective nationwide cohort study of patients with human papillomavirus (HPV)-associated cervical adenocarcinomas <2 cm undergoing radical vaginal trachelectomy, simple vaginal trachelectomy, or conization with nodal assessment between 2000 and 2022. Clinical data were retrieved from electronic medical records and institutional databases. Histological specimens were retrospectively assigned the Silva pattern classification after review by an expert gynecologic oncology pathologist. The primary endpoint was recurrence-free survival categorized by the Silva pattern classification. Survival rates were compared between groups defined by the Silva pattern classification using Kaplan-Meier estimates.

Results: Of 61 women with cervical adenocarcinoma, 59 were HPV-associated, with HPV 16 and 18 being the most prevalent genotypes. Among HPV-associated adenocarcinomas, 20 (33.9%) were classified as pattern A, 26 (44.1%) as pattern B, and 13 (22.0%) as pattern C. HPV 18 was noted in 9 (69.2%) of tumors with pattern C, compared to 7 (35.5%) and 10 (38.5%) in patterns A and B, respectively. Most cases were International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB1 (N = 50 [84.8%]). Lymphovascular invasion was present in 6 (23.1%) of cases with pattern B and in 7 (53.9%) with pattern C. There was no difference in surgical radicality between groups. Five women abandoned fertility preservation due to nodal metastasis (N = 2), positive surgical margins (N = 2), or multifocal disease (N = 1). Of these, 3 tumors exhibited pattern C, 1 pattern B with lymphovascular invasion, and 1 pattern B without lymphovascular invasion. Median follow-up was 79 months (range; 14-248 months). Five-year recurrence-free survival was 100% for the Silva patterns A and B, compared to 75.5% for pattern C (95% CI 41.6% to 91.4%).

Conclusions: Recurrence occurred exclusively among patients with the Silva pattern C, highlighting the prognostic potential of this classification system. Silva classification should be considered when counseling women regarding fertility-sparing surgery.