About Prof. Hua Kequn
Prof. Hua Kequn is a leading gynecologist and gynecologic oncologist at the Obstetrics & Gynecology Hospital, Fudan University — one of China's foremost centres for women's health, minimally invasive gynecologic surgery, and gynecologic oncology. He specialises in laparoscopic and robotic surgery for uterine fibroids, endometriosis, and gynecologic cancers, and is widely recognised as a pioneer in advanced minimally invasive techniques in China. His clinical philosophy holds that the most important obligation in gynecologic oncology is not simply to cure disease, but to preserve — wherever oncologically safe — the patient's reproductive capacity, bodily integrity, and quality of life. When a patient's circumstances demand innovation, the surgeon's responsibility is to find a way forward that no established protocol yet describes.
Case Overview
Ms. Chen (pseudonym), a 25-year-old woman in the second trimester of pregnancy, presented with vaginal bleeding and was diagnosed with cervical invasive mucinous adenocarcinoma, Stage Ib1. The diagnosis confronted Ms. Chen and her family with an agonising choice: conventional management required immediate termination of the pregnancy and radical hysterectomy — eliminating any prospect of the child she and her family desperately wished to preserve. Unwilling to accept this outcome without exploring every alternative, they sought Prof. Hua Kequn. Following MRI characterisation of the tumour and pregnancy, and multidisciplinary consultation involving gynecologic oncology, obstetrics, and anaesthesiology, Prof. Hua's team formulated a strategy without precedent: a mid-trimester laparoscopic radical trachelectomy — resecting the cervix and parametria while preserving the uterine body and the fetus in situ. The procedure lasted seven hours. The tumour was successfully excised; the fetus was preserved. Postoperative chemotherapy was tailored to support the ongoing pregnancy. Ms. Chen delivered a healthy baby girl by caesarean section at 34.1 weeks of gestation, followed by hysterectomy at the time of delivery. The case represents the world's first reported mid-trimester laparoscopic radical trachelectomy and has established a new reference point for the management of cervical cancer in pregnancy.
Diagnostic Workup
Pelvic MRI characterised the cervical tumour — confirming Stage Ib1 disease with no parametrial invasion, no regional lymphadenopathy, and no evidence of distant metastasis — and provided detailed anatomical mapping of the gravid uterus, placental position, and fetal presentation essential for surgical planning. Colposcopy-directed biopsy confirmed invasive mucinous adenocarcinoma with histological grading and receptor profiling to inform chemotherapy selection. Multidisciplinary tumour board review — gynecologic oncology, obstetrics, maternal-fetal medicine, anaesthesiology, and neonatology — assessed oncological risk, fetal viability, surgical feasibility, and the perioperative and neonatal contingency plan. Fetal wellbeing was assessed with ultrasound and Doppler studies before and after surgery.
Prof. Hua's pre-operative assessment: The oncological case for proceeding is clear — Stage Ib1 disease, no parametrial involvement, no nodal disease. The question is whether we can achieve the same oncological result as radical hysterectomy through a trachelectomy approach, in a patient who is in the second trimester of pregnancy. The uterus is enlarged, the vascularity is dramatically increased, and every step of the dissection carries risks that do not exist in the non-pregnant patient. But the anatomy is not fundamentally different — the surgical principles are the same. If we are meticulous, if the team is coordinated, and if we are prepared to adapt at every step, this is achievable. The patient deserves the attempt.
Treatment Strategy and Course
Diagnosis: Mid-Trimester Cervical Invasive Mucinous Adenocarcinoma, Stage Ib1, in a 25-year-old pregnant patient seeking fertility and fetal preservation.
Treatment principle: world's first mid-trimester laparoscopic radical trachelectomy — laparoscopic pelvic lymphadenectomy and radical cervicectomy with parametrial resection, preserving the uterine body and fetus in situ, followed by pregnancy-adapted chemotherapy and planned caesarean delivery.
- Preoperative planning: MRI-based tumour and anatomical mapping; multidisciplinary tumour board confirmation of surgical strategy; anaesthetic and neonatal contingency planning; fetal wellbeing baseline established
- Laparoscopic pelvic lymphadenectomy: Bilateral pelvic lymph node dissection under laparoscopic visualisation; all nodes sent for intraoperative frozen section — negative for metastatic disease, confirming eligibility to proceed to trachelectomy
- Radical trachelectomy — tunnelling and parametrial dissection: Meticulous laparoscopic dissection of the uterine vessels, parametria, and vesicouterine space; the "tunnel" technique used to isolate and divide the parametria while preserving uterine arterial supply to the corpus; seven hours of continuous precision dissection with the gravid uterus in the operative field throughout
- Cervical resection and uterine preservation: Cervix resected with adequate oncological margins; uterine isthmus preserved; cerclage placed at the uterine isthmus to support the ongoing pregnancy; fetal heart rate monitoring confirmed fetal wellbeing throughout and immediately postoperatively
- Postoperative chemotherapy: Pregnancy-adapted chemotherapy regimen initiated to address residual oncological risk; regimen selected for efficacy against mucinous adenocarcinoma and established fetal safety profile in the second and third trimester
- Delivery and completion surgery (34.1 weeks): Elective caesarean section at 34.1 weeks; healthy baby girl delivered; hysterectomy performed at the same operative sitting; final pathology confirmed clear margins and no residual disease
Prof. Hua's clinical reflection: What made this case possible was not any single technical innovation — it was the combination of oncological discipline, surgical precision, and the willingness of an entire multidisciplinary team to commit to a plan that had never been executed before. The lymph node result was the critical gate: negative nodes confirmed that trachelectomy was oncologically appropriate. From that point, the surgery was a question of execution — seven hours of meticulous dissection in a field that was anatomically transformed by pregnancy. The outcome — a healthy child and a mother free of disease — is what this team came together to achieve.
Expert Commentary — Prof. Hua Kequn
1. Cervical Cancer in Pregnancy: Balancing Oncological and Obstetric Priorities
Cervical cancer diagnosed during pregnancy presents one of the most complex decision frameworks in gynecologic oncology. The oncological imperative — timely, adequate treatment — must be weighed against gestational age, fetal viability, tumour stage, histology, and the patient's informed reproductive priorities. For Stage Ib1 disease diagnosed in the second trimester, the evidence supports the feasibility of deferring definitive surgery until fetal maturity in selected cases; however, the option of proceeding with fertility-sparing surgery during pregnancy — preserving both oncological adequacy and the ongoing pregnancy — had not previously been demonstrated for mid-trimester cases. The critical oncological prerequisite is negative pelvic lymph nodes: nodal metastasis fundamentally changes the risk-benefit calculation and precludes conservative management. In Ms. Chen's case, intraoperative frozen section confirmed nodal negativity, establishing the oncological basis for proceeding with trachelectomy rather than hysterectomy.
2. Laparoscopic Radical Trachelectomy in the Gravid Uterus: Technical Innovation and Surgical Principles
Radical trachelectomy — resection of the cervix, parametria, and upper vagina with preservation of the uterine corpus — is an established fertility-sparing procedure for early-stage cervical cancer in non-pregnant patients. Its application in the mid-trimester gravid uterus introduces anatomical and physiological challenges of a fundamentally different order: the uterus is substantially enlarged, displacing and distorting the operative field; uterine and parametrial vascularity is dramatically increased, elevating haemorrhage risk at every step of the dissection; and the fetus must be maintained in a stable intrauterine environment throughout a prolonged procedure. The laparoscopic approach — offering magnified visualisation, precise instrument control, and reduced uterine manipulation compared with open surgery — is the technique best suited to meeting these demands. The "tunnel" technique for parametrial dissection, isolating the parametria while preserving the uterine arterial supply to the corpus, is the key manoeuvre enabling uterine preservation in this context. Cerclage at the uterine isthmus provides structural support for the remainder of the pregnancy following cervical resection.
3. Multidisciplinary Coordination in Complex Gynecologic Oncology: The Organisational Basis for Unprecedented Outcomes
The successful execution of a procedure without precedent requires not only surgical expertise but an organisational framework capable of anticipating and managing every contingency across multiple specialties simultaneously. In Ms. Chen's case, the multidisciplinary team — gynecologic oncology, obstetrics, maternal-fetal medicine, anaesthesiology, and neonatology — was not convened to ratify a decision already made; it was convened to stress-test the proposed strategy, identify every point of potential failure, and establish a contingency plan for each. The anaesthetic protocol was designed to maintain uterine perfusion and fetal oxygenation throughout a seven-hour procedure. The neonatal team was prepared for emergency delivery at any point. The obstetric team monitored fetal wellbeing continuously. The chemotherapy regimen was selected through joint oncological and obstetric review. This level of coordination — across disciplines, across the duration of the pregnancy, and through to delivery — is the organisational achievement that made the clinical outcome possible.
How CMCS Shanghai Coordinated This Case
CMCS Shanghai supported Ms. Chen and her family throughout the diagnostic, surgical, and obstetric pathway at the Obstetrics & Gynecology Hospital, Fudan University, including: priority consultation coordination with Prof. Hua Kequn's team and the multidisciplinary tumour board; bilingual interpretation across all MDT discussions, surgical planning consultations, and obstetric appointments; bilingual explanation of the proposed trachelectomy strategy, its oncological rationale, the fetal preservation plan, and the chemotherapy and delivery pathway; coordination of MRI, colposcopy, biopsy, and fetal assessment with bilingual results communication; bilingual informed consent for each phase of treatment; intraoperative and postoperative coordination including pathology results, chemotherapy scheduling, and obstetric surveillance; and coordination of the caesarean delivery and completion hysterectomy, including neonatal support arrangements and postoperative follow-up scheduling.
For international patients facing gynecologic oncology diagnoses — including those with the additional complexity of concurrent pregnancy — Prof. Hua Kequn's team at the Obstetrics & Gynecology Hospital, Fudan University offers access to one of China's most experienced and innovative minimally invasive gynecologic oncology programmes. CMCS ensures that expertise is accessible — in the patient's language, with every step coordinated and communicated clearly.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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