No Survival Improvement From Radical Hysterectomy in Patients With Cervical Cancer, Intraoperative Detection of Positive Lymph Node Involvement

Among patients with cervical cancer, there was no significant difference found between the risk of recurrence, local recurrence, or death among individuals who either completed or abandoned a radical uterine procedure (mostly radical hysterectomy) following the intraoperative detection of a positive pelvic lymph node (LN), according to a study presented at the ESMO Virtual Congress 2020.

The speaker at the conference presenting the study was David Cibula, MD, PhD, professor of the Gynaecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic. Cibula explained during his presentation that current clinical practice is divided between 2 types of management of patients with cervical cancer who are diagnosed with positive pelvic LNs intraoperatively.

However, Cibula noted that the management approach of conducting extensive surgical dissection in the pelvis followed by pelvic radiotherapy is associated with higher morbidity. He explained that for this reason, his research team was interested in investigating the other dominant approach to disease management, which is the completion of a radical uterine procedure, in order to assess whether mortality would improve in these patients.

The research team conducted the ABRAX study to assess whether the completion of radical hysterectomy improved patient outcomes. The multicenter, retrospective, cohort study was comprised of 515 patients who were referred to have primary surgery conducted with a curative intent between 2005 and 2015 for stage IA-IIB tumors. All of the patients included were found to be LN-positive (N1) during surgery, with the LNs found to have a metastasis greater than or equal to 0.2 mm.

Patients were then stratified into 2 subgroups: the COMPL group of 361 patients, in whom a uterine procedure was completed as planned and the ABAND group of 154 patients, in whom a uterine procedure was abandoned based on intraoperative detection of LN positivity. Of those patients who had a completed uterine procedure in the ABAND group, 92.8% had a radical hysterectomy, 3.9% had a simple hysterectomy, 2.5% had a radical trachelectomy, and 0.6% had a simple trachelectomy.

During the study, the traditional prognostic markers, such as tumor size, tumor type, and disease stage, were balanced between both the ABAND group and the COMPL group. The researchers also matched the propensity scores in order to ensure the outcome endpoints were not influenced by the type of management conducted after removal of other potentially relevant covariates.

In the COMPL group, an additional treatment of adjuvant chemoradiation was administered in 75% of patients, combined radiotherapy was administered in 13% of patients, and chemotherapy was administered in 17% of patients. In the ABAND group, an additional treatment of primary chemoradiation was administered in 93% of patients and primary combined radiotherapy was administered in 7% of patients.

Upon assessment at the median follow-up point of 48.9 months, 74% (381) of patients were able to maintain their disease-free state. Additionally, the researchers observed no significant difference between the 2 groups regarding risk of recurrence, local recurrence, or death.

In the subgroup analyses, the researchers did not identify a group of patients who demonstrated a survival benefit following the completion of a uterine surgery. Among both groups, increasing International Federation of Gynecology and Obstetrics stage and the tumor size greater than or equal to 4 cm were identified as major prognostic factors associated with recurrence and poorer survival risk.

The authors were able to determine based on these findings that the completion of a radical uterine procedure in patients with intraoperative detection of positive LNs did not improve survival, regardless of tumor size or type.

For this reason, the authors noted that if a pelvic LN involvement is diagnosed during surgery, it may be necessary to consider abandoning the planned uterine procedure. Following this, the authors recommend referring the patient to receive definitive chemoradiation.

REFERENCE

No Survival Advantage From Radical Hysterectomy in Patients With Cervical Cancer and Intraoperative Detection of Positive Lymph Node Involvement. Geneva, Switzerland: ESMO; September 22, 2020. esmo.org/meetings/esmo-virtual-congress-2020/meeting-resources/scientific-news/no-survival-advantage-from-radical-hysterectomy-in-patients-with-cervical-cancer-and-intraoperative-detection-of-positive-lymph-node-involvement. Accessed September 24, 2020.