Association of preoperative cone biopsy with recurrences after radical hysterectomy

Preoperative conization in cervical cancer patients undergoing open abdominal radical hysterectomy: Results from a propensity-score matched study

OBJECTIVE

Conization is a common diagnostic tool in cervical cancer, but its prognostic impact prior to abdominal radical hysterectomy remains unclear. This study examines conization's influence on outcomes in early and advanced cervical cancer, the significance of cone specimen resection margins, and the impact of hysterectomy timing post-conization.

METHODS

Data from the Leipzig Mesometrial Resection (MMR) trial were retrospectively analyzed for patients with primary cervical cancer staged IB1-IIB (2009-FIGO). Open abdominal radical hysterectomy was performed as total or extended mesometrial resection (TMMR/EMMR). Propensity score matching and survival comparisons were conducted using the Kaplan-Meier method and Cox proportional hazards regression modeling.

RESULTS

Among 542 patients, 202 had conization during diagnostic workup. After 1:1 propensity score matching (163 patients per group), preoperative conization was associated with better recurrence-free (95.6 % vs. 82.3 %, HR 3.2, 95 % CI 1.4-7.0, p < 0.01) and overall (99.2 % vs. 85.6 %, HR 6.3, 95 % CI 1.9-21.1, p < 0.001) survival. In a multivariable Cox regression model, conization independently improved recurrence-free survival (HR 0.3, 95 % CI 0.1-0.6, p < 0.01). The cumulative risk of distant recurrence was significantly higher without conization (sHR 14.9, 95 % CI 1.9-114.9, p = 0.01), with no difference in local recurrences. Completeness of tumor removal by conization (R-status) had no prognostic impact. Delayed radical hysterectomy ≥28 days post-conization was associated with improved overall survival (p = 0.02).

CONCLUSION

Preoperative conization was associated with improved survival in cervical cancer patients undergoing open abdominal radical hysterectomy, irrespective of resection margin, nodal status, or parametrial involvement. Delaying radical hysterectomy by ≥28 days post-conization further enhanced survival and reduced distant metastases.

Outcomes of Radical Hysterectomy for Early-Stage Cervical Carcinoma, with or without Prior Cervical Excision Procedure

OBJECTIVE

To investigate the impact of a prior cervical excisional procedure on the oncologic outcomes of patients with apparent early-stage cervical carcinoma undergoing radical hysterectomy.

METHODS

The National Cancer Database (2004-2015) was accessed, and patients with FIGO 2009 stage IB1 cervical cancer who had a radical hysterectomy with at least 10 lymph nodes (LNs) removed and a known surgical approach were identified. Patients who did and did not undergo a prior cervical excisional procedure (within 3 months of hysterectomy) were selected for further analysis. Overall survival (OS) was evaluated following the generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control a priori-selected confounders.

RESULTS

A total of 3159 patients were identified; 37.1% (n = 1171) had a prior excisional procedure. These patients had lower rates of lymphovascular invasion (29.2% vs. 34.9%, p = 0.014), positive LNs (6.7% vs. 12.7%, p < 0.001), and a tumor size >2 cm (25.7% vs. 56%, p < 0.001). Following stratification by tumor size, the performance of an excisional procedure prior to radical hysterectomy was associated with better OS even after controlling for confounders (aHR: 0.45, 95% CI: 0.30, 0.66). The rate of minimally invasive surgery was higher among patients who had a prior excisional procedure (61.5% vs. 53.2%, p < 0.001). For these patients, performance of minimally invasive radical hysterectomy was not associated with worse OS (aHR: 1.37, 95% CI: 0.66, 2.82).

CONCLUSIONS

For patients undergoing radical hysterectomy, preoperative cervical excision may be associated with a survival benefit. For patients who had a prior excisional procedure, minimally invasive radical hysterectomy was not associated with worse overall survival.

Survival after minimally invasive radical hysterectomy with protective colpotomy for early-stage cervical cancer: A systematic review and meta-analysis

Minimally invasive surgery on treatment of early-stage cervical cancer is debatable. Traditional approaches of colpotomy are considered responsible for an inferior oncological outcome. Evidence on whether protective colpotomy could optimize minimally invasive technique and improve prognoses of women with early-stage cervical cancer remains limited. We produced a systematic review and meta-analysis to compare oncological outcomes of the patients treated by minimally invasive radical hysterectomy with protective colpotomy to those treated by open surgery according to existing literature. We explored PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to December 2022. Inclusion criteria were: (1) randomized controlled trials or observational studies published in English, (2) studies comparing minimally invasive radical hysterectomy with protective colpotomy to abdominal radical hysterectomy in early-stage cervical cancer, and (3) studies comparing survival outcomes. Two reviewers performed the screening, data extraction, and quality assessment independently. A total of 8 retrospective cohort studies with 2020 women were included in the study, 821 of whom were in the minimally invasive surgery group, and 1199 of whom were in the open surgery group. The recurrence-free survival and overall survival in the minimally invasive surgery group were both similar to that in the open surgery group (pooled hazard ratio, 0.88 and 0.78, respectively; 95% confidence interval, 0.56-1.38 and 0.42-1.44, respectively). Minimally invasive radical hysterectomy with protective colpotomy on treatment of early-stage cervical cancer had similar recurrence-free survival and overall survival compared to abdominal radical hysterectomy. Protective colpotomy could be a guaranteed approach to modifying minimally invasive technique.

Radical Hysterectomy With Preoperative Conization in Early-Stage Cervical Cancer: A Systematic Review and Pairwise and Network Meta-Analysis

OBJECTIVE

The investigation of the role of preoperative conization in cervical cancer aiming to explore its potential clinical significance.

DATA SOURCES

Cochrane Library, Embase, PubMed, and Web of Science, up to April 28, 2023.

METHODS OF STUDY SELECTION

(1) Observational cohort studies, (2) studies comparing radical hysterectomy with preoperative conization (CO) vs radical hysterectomy without preoperative conization (NCO) in patients with early-stage cervical cancer, and (3) studies comparing disease-free survival outcomes.

TABULATION, INTEGRATION, AND RESULTS

Two reviewers independently extracted the data and assessed the quality of the studies. The meta-analysis used combined hazard ratios along with their corresponding 95% confidence intervals to compare CO and NCO. We conducted a Bayesian network meta-analysis using Markov chain Monte Carlo methods to compare minimally invasive CO, open CO, minimally invasive NCO, and open NCO. Our study included 15 retrospective trials, 10 of which were used to traditional pairwise meta-analysis and 8 for network meta-analysis. The NCO group exhibited a notably higher probability of cancer recurrence than the CO group (hazard ratio, 0.52; 95% confidence interval, 0.41-0.65). In the network meta-analysis, minimally invasive NCO showed the worst survival outcome.

CONCLUSION

Preoperative conization seems to be a protective factor in decreasing recurrence risk, assisting clinicians in predicting survival outcomes for patients with early-stage cervical cancer. It may potentially aid in selecting suitable candidates for minimally invasive surgery in clinical practice.

Robotic radical hysterectomy after conization for patients with small volume early-stage cervical cancer

Laparoscopy and robotics are recommended for managing gynecological cancer, as they are associated with lower morbidity and comparable outcomes to open surgery. However, in the case of early cervical cancer, new evidence suggests worse oncological outcomes with these approaches compared to open surgery, though the limited number of robotic cases makes it challenging to draw definitive conclusions for this particular approach. The prior conization has been proposed as a strategy to reduce the risk of tumor spillage and contamination during minimally invasive (MIS) radical hysterectomy (RH). Retrospective studies have indicated that undergoing conization before RH is linked to a reduced risk of recurrences, especially in cervical tumors measuring less than 2 cm. Nevertheless, these studies lack the statistical power needed to definitively establish conization as a recommended step before RH. Furthermore, these studies do not have enough cases utilizing the robotic approach and specific conclusions cannot be drawn from this technique. The question of whether a subset of cases would benefit from preoperative conization and whether conization should be performed to recommend MIS over open surgery remains unanswered. Prospective clinical trials involving women diagnosed with early-stage cervical cancer <2 cm, randomized between undergoing conization before robotic RH or without prior conization are mandatory to assess the role of conization before robotic RH in cervical cancer.

Statement of the Uterus Commission of the Gynecological Oncology Working Group (AGO) on Surgical Therapy for Patients with Stage IA2-IIB1 Cervical Cancer

The presentation of the results of the prospective randomized international multicenter study AGO-OP.8 - CCTG CX.5 - SHAPE at the annual conference of the American Society of Clinical Oncology (ASCO) in 2023 will affect the surgical treatment of early-stage cervical cancer. In the SHAPE study, simple total hysterectomy (experimental arm) was found to be non-inferior to radical hysterectomy (standard arm) to treat patients with early-stage cervical cancer (FIGO stages [2018] IA2 - IB1 ≤ 2 cm with an infiltration depth of < 1 cm); after 3 years' follow-up the pelvic recurrence rate was 2.52% (experimental arm) compared to 2.17% (standard arm) with no statistically significant difference with regards to recurrence-free survival and overall survival rates. After weighing up the results of the SHAPE study published at the conference, the Uterus Organ Commission of AGO is of the opinion that, in addition to the use of radical hysterectomy to treat patients with invasive cervical cancer which is FIGO stage IA2 - IB1 ≤ 2 cm with an infiltration depth of < 1 cm, simple total hysterectomy may also be considered for primary surgical therapy on a case-by-case basis after suitable explanation of the associated risks. It will be necessary to wait for the data of the full publication before discussing whether this approach should be included in official guidelines and defining it as a new therapy standard.

Effect of preoperative cervical conization before hysterectomy on survival and recurrence of patients with cervical cancer: A systematic review and meta-analysis

OBJECTIVE

Conization plays a therapeutic and diagnostic role in cervical cancer. We conducted a systematic review and meta-analysis to compare the clinical outcomes of patients with cervical cancer who underwent hysterectomy with versus without preoperative cervical conization.

METHODS

In this meta-analysis, we analyzed studies published in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), and Clinical Trials. gov that appeared in our search from inception to May 1, 2022.

RESULTS

Eleven studies with 4184 participants were included in this review. There were 2122 patients in the preoperative conization group and 2062 patients in the non-conization group. The meta-analysis showed that disease free survival (DFS) (hazard ratio [HR]: 0.23; 95% CI: 0.12-0.44; 1616 participants; P = 0.030) and overall survival (OS) (HR: 0.54; 95% CI: 0.33-0.86; 1835 participants; P = 0.597) were improved in the preoperative conization group compared with those in the non-conization group. The risk for recurrence was lower in the preoperative conization group than in the non-conization group (odds ratio [OR]: 0.29; 95% CI: 0.17-0.48; 1099 participants; P = 0.434). There was no significant statistical difference regarding intraoperative adverse events (OR: 0.81; 95% CI: 0.18-3.70; 530 participants; P = 0.555) and postoperative adverse events (OR: 1.24; 95% CI: 0.54-2.85; 530 participants; P = 0.170) between the preoperative conization group and non-conization group. In subgroup analysis, patients who benefited more from preoperative conization, had underwent minimally invasive surgery, had smaller local tumor lesions, and had no lymph node involvement.

CONCLUSIONS

Preoperative conization before radical hysterectomy may have a protective effect in the treatment of early cervical cancer, with better survival and less recurrence, especially when the patient is at an early stage and undergoes minimally invasive surgery.

Association of preoperative conization with recurrences after laparoscopic radical hysterectomy for FIGO 2018 stage IB1 cervical cancer

Objective

To evaluate association of preoperative conization with recurrences after laparoscopic radical hysterectomy (LRH) for FIGO 2018 stage IB1 cervical cancer.

Methods

This is a retrospective single-center study. Patients who underwent LRH for cervical cancer with squamous, adenosquamous and adenocarcinoma subtype from January 2014 to December 2018 were reviewed. All patients were restaged according to the 2018 FIGO staging system. Those who were in FIGO 2018 stage IB1 met the inclusion criteria. General characteristics and oncologic outcomes including recurrence-free survival (RFS) were analyzed.

Results

A total of 1273 patients were included in the analysis. 616 (48.4%) patients underwent preoperative biopsy, and 657 (51.6%) patients underwent conization. Residual disease was observed in 822 (64.6%) patients. During a median follow-up of 50.30 months, 30 (2.4%) patients experienced recurrence. The univariate analysis showed that patients who had larger tumor diameter, the presence of residual tumor at final pathology, and underwent adjuvant treatment had a significant higher risk of recurrence (P < 0.01). Conversely, patients who underwent conization were significantly less likely to experience recurrence (P = 0.001). In the multivariate analysis, the independent risk factor associated with an increased risk of recurrence was resident macroscopic tumor (HR: 38.4, 95% CI 4.20–351.64, P = 0.001). On the contrary, preoperative conization was associated with a significantly lower risk of recurrence (HR: 0.26; 95% CI 0.10–0.63, P = 0.003). The Kaplan–Meier curves showed patients who underwent conization had improved survival over those who underwent biopsy (5 year RFS: 98.6 vs 95.1%, P = 0.001). The 5 year RFS of patients with residual tumor was significantly different (R0: 99.2%, R1: 97.4%, R2: 93.6%, P < 0.001), especially the patients with residual macroscopic tumor after conization (R0: 99.5%, R1: 99.0%, R2:92.4%, P = 0.006).

Conclusion

Preoperative conization and the absence of residual tumor at the time of surgery might play a protective role in patients with FIGO 2018 IB1 cervical cancer following LRH, which support the theory of the influence of intraoperative tumor spread during radical hysterectomy. Further prospective evidence is needed.