Consequences of inadvertent, suboptimal primary surgery in carcinoma of the uterine cervix

Survival outcome and prognostic factors post inadvertent hysterectomy in carcinoma cervix treated with salvage chemo-radiation

INTRODUCTION

The standard of care for treating early invasive cervical cancer is radical hysterectomy or radiation alone while chemo-radiation is a definitive treatment for advanced disease. Occasionally, a simple hysterectomy is performed in the cancer cervix and these patients merit adjuvant treatment in view of the high chances of loco-regional recurrences. The aim of the study was to analyze the survival outcome of these patients treated with salvage chemo-radiotherapy and also to determine the prognostic factors affecting survival.

MATERIALS AND METHODS

The medical records of all patients with cervical cancer post simple hysterectomy outside and who received salvage treatment in our department between 2014 and 2020 were retrieved. The data regarding clinical, treatment details and survival were analyzed.

RESULTS

A total of 198 patients were included. Median follow-up duration was 45.5 months. Gross disease and lymphadenopathy were seen in 60% and 28% patients, respectively. The 5-year progression-free survival(PFS) and overall survival(OS) was 75% and 76%, respectively. Concurrent chemotherapy alone or in combination with induction chemotherapy using three-drug regimens showed better survival compared to those treated by radiation alone. On multivariate analysis, factors found to be adversely affecting OS and PFS were lymph node (LN) size of more than 2 cm, non-squamous histology, overall treatment time(OTT) of more than 12 weeks and use of non three-drug chemotherapy regimen.

CONCLUSION

Subtotal hysterectomy results in a higher incidence of local recurrence of disease. Factors that impair the outcome in this sub-group of patients are gross lymphadenopathy, non-squamous histology and prolong OTT.

Standardization and experience may influence the survival of laparoscopic radical hysterectomy for cervical cancer

OBJECTIVE

Minimally invasive radical hysterectomy has been shown to be associated with poorer outcome in an influential prospective, randomized trial. However, many centers worldwide performing minimally invasive radical hysterectomy have data and experience that prove otherwise. We aim to review surgical and oncologic outcomes of patients operated by Laparoscopic Radical Hysterectomy in a tertiary hospital, by experienced surgeons and standardization in radicality, for cervical carcinoma Stage 1A1-1B1 from January 2009 to May 2014.

MATERIALS & METHODS

Standardised surgical technique with Parametrium & Paracolpium resection approach was adopted by qualified and experienced Gynecologic/Gyne-Oncologic Endoscopic & Minimally Invasive Surgeons in performing Laparoscopic Radical Hysterectomy for Cervical Cancer stage 1A1-1B1 from January 2009-May 2014, involving 53 patients. Electronic Medical Record system (EMR) Of Chang Gung Memorial Hospital(Tertiary Referral Centre), Department of Obstetrics & Gynecology was accessed for surgical and oncologic outcomes.

RESULTS

Fifty-Three patients operated from January 2009 to May 2014 were followed up for an average of 96.7 months with longest follow-up at 127 months. There were no cases of recurrence or death reported. 5 Year - Survival Rate and 5 Year Disease-Free Survival Rate were 100%. Two patients received post-operative pelvic radiation concurrent with chemotherapy using Cisplatin due to greater than 1/3 cervical stromal invasion.

CONCLUSION

It is vital to standardize minimally invasive surgical techniques for early stage cervical cancer, with focus on adequate radicality and resection which may contribute to excellent survival outcomes. Further international multi-center randomized trial (Minimally Invasive Therapy Versus Open Radical Hysterectomy In Cervical Cancer) will provide justification for continued practice of MIS in early stage cervical cancer.

Complementary surgery for cervical cancer patients inadequately treated with extrafacial hysterectomy

OBJECTIVE

To evaluate surgical outcomes and survival outcomes of cervical cancer patients who underwent complementary surgery after an extrafacial hysterectomy METHODS: Patients with cervical cancer, who underwent extrafacial hysterectomy initially and thereafter underwent complementary surgery were reviewed retrospectively. Complementary surgery consisted of radical parametrectomy, proximal vaginectomy and pelvic lymphadenectomy.

RESULTS

Twenty patients were evaluated. Histopathologic subtype was squamous cell carcinoma in twelve patients, adenocarcinoma in six patients and adenosquamous carcinoma in two patients. Route of surgery was laparotomy in 19 patients and laparoscopy in one patient. Two patients were staged as stage 1A2, nine were staged as stage 1B1, four were staged as stage 1B2, one was staged as stage 2A1, one was staged as stage 2B and three were staged as stage 3C1. The median tumor size was 16.5 (Range, 4-40) mm. Grade ≥ 3 complications related to surgery occured in 8 (40%) patients. Four of them were managed intraoperatively and recovered problem free. Remaining four (20%) needed reoperation. Pathology reports revealed involvement of parametrium in one (5%) patient, involvement of the proximal vagina in one (5%) patient, matastasis to pelvic lymph nodes in 3 (15%) patients. Five (25%) patients received adjuvant radiotherapy. Consequently, 5-year and 10-year cumulative survival was calculated as 94%.

CONCLUSION

Complementary surgery and radiotherapy show similar oncologic outcomes in patients with early-stage cervical cancer who had undergone simple hysterectomy initially. Complementary surgery is associated with slightly higher rate of morbidity compared with radiotherapy, however significant proportion of complications can be noticed and repaired intraoperatively.

Comparison of oncologic outcomes of unanticipated cervical carcinoma in women undergoing inadvertent simple hysterectomy and those undergoing surgical treatment after preoperative diagnosis

OBJECTIVES

To determine the proportion of women with undiagnosed cervical carcinoma before simple hysterectomy and its causes and to compare the oncologic outcomes of women diagnosed and treated with standard therapy to those undergoing inadvertent simple hysterectomy with subsequent treatment.

METHODS

Medical records were reviewed for patients with cervical carcinoma who underwent hysterectomy between 1 January 2004 and 31 December 2014. Demographic data, chemotherapeutic agents, and response rates were analyzed using descriptive statistics. The categorical variables were compared using chi-square or Fisher's exact test. The continuous data were compared using the independent t-test and Mann-Whitney test, as appropriate. The Kaplan-Meier method was used to evaluate the survival outcomes.

RESULTS

Of the 526 patients with cervical carcinoma who underwent hysterectomy, 57 patients (10.8%) were diagnosed with cervical carcinoma after simple hysterectomy. After excluding 121 patients with invasion of <3 mm and without lymphovascular space invasion (LVSI), 353 patients were preoperatively diagnosed with cervical carcinoma stage IA1 with LVSI to IIA and underwent proper surgical treatment. Fifty-two patients were encountered for inadvertent hysterectomy. Forty-four of 52 patients in the inadvertent hysterectomy group consented to subsequent treatment, with 43 patients receiving concurrent chemoradiotherapy and one undergoing additional surgery. The median time before subsequent treatment initiation was 1.6 months [0.5-9.2 months]. The 5-year DFS rates of the standard surgical treatment group and inadvertent hysterectomy group were 88.4% vs. 93.2%, respectively (P = 0.147). The 5-year OS rates of the standard surgical treatment group and the inadvertent hysterectomy group were 98.9% vs. 100%, respectively (P = 0.767).

CONCLUSIONS

Women with cervical carcinoma who had small tumors and underwent inadvertent simple hysterectomy with appropriate consequent management had oncologic outcomes comparable to those in the standard surgical treatment group.

Occult invasive cervical cancer after simple hysterectomy: a multi-center retrospective study of 89 cases

Background

Occult invasive cervical cancer (OICC) is sometimes incidentally found in surgical specimens after a simple hysterectomy (SH). This study was aimed at identifying a subset of patients with OICC who have a favorable prognosis. This patient group may not require adjuvant radiotherapy and other procedures.

Methods

The medical records of women in whom OICC was detected after an inadvertent SH were retrospectively reviewed. The relevant data, including clinicopathological characteristics, treatment and clinical outcome were evaluated. The primary and secondary endpoints were overall survival (OS) and relapse-free survival (RFS), respectively.

Results

Eighty-nine patients who met the inclusion criteria were included for analysis, and the risk of OICC was found to be 1.9 %. Finding an invasive cancer in a hysterectomy specimen after a conization procedure that shows positive margins was the most common reason (41.6 %) for the performance of inadvertent SH. In the univariate analysis, a tumor width > 20 mm, deep stromal invasion, and lymph node metastasis (LNM) were adversely associated with relapse (P < 0.001, < 0.001, and = 0.001, respectively) and survival (P = 0.003, 0.004, and 0.027, respectively), although these parameters were not independently associated with patient prognoses in the multivariate analysis. In patients with a tumor width ≤ 20 mm and superficial stromal invasion in the observation subgroup, the 5-year RFS and 5-year OS were both 100 %, whereas they were 57.1 % and 66.7 %, respectively, in patients with a tumor size > 20 mm and deep stromal invasion in the radiotherapy or chemotherapy subgroup (P < 0.001, and = 0.008, respectively).

Conclusions

Simple observation after a lymphadenectomy procedure may be feasible in OICC patients with a tumor width ≤ 20 mm, superficial stromal invasion, a negative section margin in hysterectomy specimens, and no LNM.

Laparoscopic nerve-sparing radical parametrectomy for occult early-stage invasive cervical cancer after simple hysterectomy

OBJECTIVE

To investigate the feasibility and surgical outcomes of laparoscopic nerve-sparing radical parametrectomy (LNSRP) and lymphadenectomy for treatment of occult early-stage invasive cervical cancer after simple hysterectomy.

METHODS

From 2006 to 2010, 28 patients who were discovered to have occult early-stage invasive cervical cancer after a simple hysterectomy underwent LNSRP, upper vaginal resection, and pelvic lymphadenectomy. A retrospective analysis of these cases was performed.

RESULTS

All patients underwent successful LNSRP. There was no conversion to laparotomy. The mean ± SD operation time was 173.30 ± 56.20 minutes. The mean ± SD estimated blood loss was 230.00 ± 109.55 mL. Two intraoperative complications were recorded. The median number of extracted pelvic and para-aortic lymph nodes was 23 (range, 12-36) and 7 (range, 3-15), respectively. The mean ± SD time before Foley catheter removal was 5.6 ± 2.74 days (range, 3-14 days ), and bladder voiding function recovery to grade 0 to grade 1 was observed in 26 patients (92.9%). Of the 28 patients, 3 patients received further adjuvant therapy. The median follow-up period was 38 (range, 4-62) months for all patients. No recurrence case was found in this series.

CONCLUSION

Laparoscopic nerve-sparing radical parametrectomy is a therapeutic option for occult early-stage invasive cervical cancer discovered after hysterectomy. Nerve-sparing radical surgery in indicated patients may lead to optimal preservation of bladder function.

An Occult Invasive Cervical Cancer Found After a Simple Hysterectomy: A 10-Year Experience in a Single Institution

Objective

The aim of this study was to identify patients who are at risk of a recurrence and those needing adjuvant treatment by risk grouping in invasive cervical cancer after a simple hysterectomy (SH).

Methods

During 2000–2009, 26 patients who underwent SH and were finally diagnosed with stages higher than IA1 were reviewed retrospectively. The American Joint Committee on Cancer (AJCC) pathologic staging system was adopted. Based on the pathologic findings, the criteria for risk scoring was set: 1 for depth of invasion (DOI) is between 3–5 mm, and 2 for DOI greater than 5 mm; 1 for longest diameter (LD) is between 0.7–20 mm, and 2 for LD greater than 20 mm; 1 for lymphovascular space invasion positive; and 3 each for parametrium, resection margin, and lymph node positive. The final score was calculated by summing up the risk scores. The receiver operation characteristic curve was created to confirm the best cutoff value.

Results

All patients were stage IA2 to IB2, of which the number of patients in stages IA2, IB1, and IB2 were 1, 24, and 1, respectively. Eleven patients did not receive any further treatment. Of the remaining 15 patients, 11 received radiation therapy, 3 underwent concurrent chemoradiation therapy, and 1 received chemotherapy alone. No patient underwent a radical parametrectomy. During a median follow-up of 67 months (range, 9–122 months), 3 patients (11.5%) showed a recurrence. Patient whose score was 1 to 3, 4 to 5, and 6 or higher was classified into low-risk, intermediate-risk, and high-risk groups, respectively. All patients in the low-risk group did not recur without any adjuvant treatment (sensitivity, 100%; specificity 34.8–65.2%).

Conclusions

Adjuvant treatment can be omitted in low-risk group patients with invasive cervical cancer detected after SH.

Management of occult invasive cervical cancer found after simple hysterectomy

BACKGROUND

To estimate safety and efficacy of radical parametrectomy (RP) and radiation therapy (RT) or concurrent chemoradiation therapy (CCRT) for patients with occult invasive cervical cancer found after simple hysterectomy.

MATERIALS AND METHODS

We retrospectively evaluated outcomes in 147 patients with occult invasive cervical cancer.

RESULTS

Forty-eight patients with IA1 lesions (IA1 group) did not receive further treatment. Of the 99 patients with IA2-IIA lesions, 26 received no definitive treatment (observation group), 44 received RT or CCRT (RT/CCRT group), and 29 underwent RP (RP group). After a median follow-up of 116 months (range 3-235 months), recurrent disease was observed in 0%, 34.6%, 6.8%, and 0% of patients in the IA1, observation, RT/CCRT, and RP groups, respectively. In the RT/CCRT group, treatment was delayed due to severe diarrhea in 4 patients (9%) and 12 patients (27%) had late complications related to RT requiring further management (including two surgical interventions). Five patients in the RP group (17%) experienced perioperative complications which were easily managed, intraoperatively or conservatively. Late complications were not observed in the RP group.

CONCLUSION

Although RP and RT/CCRT had similar therapeutic efficacy, the lower rate of late complications observed with RP makes it preferable to RT/CCRT.

[Laparoscopic management of occult cervical cancer discovered after simple hysterectomy]

OBJECTIVES

To assess the feasibility and morbidity of surgical management by combined laparoscopic and vaginal approach after cervical cancer diagnosed at the time of simple hysterectomy.

PATIENTS AND METHODS

From 2000 to 2005, 10 patients were referred with occult cervical cancer discovered after simple hysterectomy. All these patients had laparoscopy for surgical staging.

RESULTS

Eight on ten patients had complete laparoscopic staging: pelvic lymphadenectomy (N=8), radical colpectomy (N=5). Operative time, pelvic lymph nodes resected, postoperative stay were respectively 261.3 minutes (200-400), 27 (23-38), 4.4 days. There were 2 symptomatic lymphocysts. Pelvic lymph nodes were positive for 1 patient with negative paraaortic nodes. Residual disease was present in 2 cases: 1 parametrial and vaginal involvement, 1 ovarian metastasis. 5 patients had adjuvant treatment: 2 combined pelvic external radiotherapy and brachytherapy, 1 pelvic external radiotherapy, 1 pelvic concurrent chemoradiation and 1 brachytherapy only. Two on ten patients needed a laparoconversion, one for ovarian involvement and one for technical failure. With a median follow-up of 29.7 months (4-63), 3 patients recurred. 3 patients recurred above 5 patients with pelvic lymphadenectomy but without parametrectomy versus no recurrence above 5 patients with pelvic lymphadenectomy and parametrectomy.

DISCUSSION AND CONCLUSION

Surgical staging of occult cervical cancer discovered after simple hysterectomy is necessary for indication of adjuvant treatment. Laparoscopy combined with vaginal surgery is feasible and safe, inducing fewer adhesions which is important for adjuvant radiotherapy. The realization of a radical parametrectomy seems to offer a local control of the disease and a decrease in the risk of recurrence, which need to be confirmed by conducting a study with more patients. This emphasize the necessity of creating a national record to register all women managed for occult cervical cancer.

Radical reoperation for invasive cervical cancer found in simple hysterectomy

OBJECTIVE

To evaluate the patients with invasive cervical cancer found in simple hysterectomy and who were subjected to radical parametrectomy and upper vaginectomy with therapeutic lymphadenectomy.

METHODS

Twenty-seven patients who underwent the radical parametrectomy and upper vaginectomy with therapeutic lymphadenectomy procedure from 1986 to 2004 were retrospectively reviewed.

RESULTS

The mean age at the time of diagnosis was 49.85 (range 38-72). The histopathological diagnoses were SCC, adenocarcinoma, adenosquamous carcinoma, endometroid carcinoma, and anaplastic carcinoma in 70.4%, 11.4%, 7.4%, 7.4%, and 3.7% of patients, respectively. Operative complications occurred in only five patients (18.5%). Following radical surgery, residual disease was found in 10 patients (37.03%). The lymph node involvement rate was 22.2% (6 patients). The recurrence rate was 7.4% (2 of 27 patients). The overall disease-free survival rate was 88.67%. The overall survival rate was 88.89%; it was significantly lower in the presence of the following factors: anaplastic carcinoma, vaginal apex metastasis, and pelvic lymph node metastasis.

CONCLUSION

This series suggests the excellent overall survival of patients that underwent radical surgery. We recommend the surgical treatment of such selected patients in experienced centers only with expert surgeons and primary adjuvant radiotherapy may be recommended in selected patients.

Laparoscopic assisted parametrectomy/upper vaginectomy (LPUV)—technique, applications and results

OBJECTIVE

In this analysis, we summarize our experiences with the laparoscopic parametrectomy/upper vaginectomy (LPUV) as a treatment option for patients with an unexpected finding of cervical cancer after simple hysterectomy as well as for patients with cancer of the vaginal cuff.

METHODS

From 1995-2004, 6 of our patients underwent LPUV including 5 patients with stage Ib(1) cervical cancer and one patient with Ia(1) cervical cancer. Prior procedures were TVH (n = 3), TAH (n = 2) or LAVH (n = 1). Charts were reviewed and follow-up data were collected.

RESULTS

Mean age was 40.5 (38-49) years and Quetelet index was 31.5 (25-40) kg/m(2). Average time from hysterectomy to LPUV was 54 (30-84) days. Retrospective FIGO staging revealed stage Ib(1) (n = 5) and stage Ia(1) (n = 1) cervical cancer. Mean duration of surgery was 207 (151-265) min, average blood loss 300 (100-500) mL. One patient had an intraoperative bladder injury and one patient a bowel injury. Histopathological evaluation found residual adenocarcinoma in situ in one patient and no malignancy in all other specimen. All pelvic (average 22 (10-36) nodes, n = 6) and paraaortic nodes (9 nodes, n = 1) were negative for malignancy. One patient had postoperative hematocrit drop and required blood transfusion, mean hematocrit difference pre- vs. postoperative was 6.4 (0.2-10.9) %. There were no further postoperative complications during the average hospital stay of 3.5 (2-5) days. No patient required adjuvant therapy after the operation. There were no recurrences or late complications in an average of 21.5 (3-50) months of follow-up.

CONCLUSION

LPUV is an alternative to open parametrectomy or radiation therapy in patients with unexpected cervical cancer after simple hysterectomy or cancer of the vaginal stump. Bladder injuries must be considered to be a specific complication of this otherwise safe procedure.