Surgical outcomes of patients with stage IA2 cervical cancer treated with radical hysterectomy

Surgical Outcomes in Early-Stage Cervical Cancer Following Radical Hysterectomy in a Resource-Limited Setting: The Experience of the National Cancer Institute (Apeksha Hospital, Maharagama), Sri Lanka

Introduction Cervical carcinoma is the commonest gynecological malignancy in Sri Lanka, and this incidence is rising. Radical hysterectomy is the preferred treatment for stages IB1, IB2, and selected cases of stages IIA1. Although surgery is feasible unless the parametrium is involved, careful patient selection is crucial in order to prevent the patient from receiving a dual mode of radical treatment (surgery and radiotherapy). Pre-operative imaging with MRI and PET-CT can accurately determine the tumor size and the lymph node metastasis. In a resource-limited setting, management is challenging as access to MRI and PET-CT is limited. This study was carried out to evaluate the surgical outcomes, five-year survival, and disease-free survival following radical hysterectomies at the National Cancer Institute, Sri Lanka, which performs the largest number of radical hysterectomies annually in the country. Methods Seventy-four patients who underwent radical hysterectomy, along with pelvic lymphadenectomy, between July 2015 to January 2017 at the National Cancer Institute, Sri Lanka (Apeksha Hospital Maharagama), were reviewed retrospectively, analyzing their clinical data and histopathological findings. Univariate analysis was performed to identify associated factors and mean survival. The Kaplan-Meier method was used for survival analysis. Results With a median follow-up of 63.5 months, five-year disease-free survival was 94.5%, and the five-year overall survival was 95.9%. There is a statistically significant association between mean survival and the cell type, presence of LVSI, and residual tumor on the hysterectomy specimen. Only four patients developed recurrences and four patients died during the follow-up. Eighteen (24.3%) patients needed blood transfusion postoperatively and no cases of bladder or bowel dysfunction in the one year post-operatively. Thirty patients (40.5%) required postoperative adjuvant treatment. Conclusions This analysis shows excellent surgical and oncological outcomes following radical hysterectomy as a primary treatment and comparable five-year disease-free survival with available global figures, despite the multiple scarcity of resources. Further studies are needed to assess the national-level status, and limited access to imaging during surgical planning poses a risk for patients receiving dual modes of radical treatment.

Less extensive surgery for patients with FIGO stage IA2 cervical cancer: A population-based study

OBJECTIVES

The objectives of this study were to study the feasibility of less extensive surgeries for stage IA2 cervical cancer and to examine the incidence of positive nodes in stage IA2 cervical cancer.

METHODS

Patients with stage IA2 cervical cancer treated surgically between 1998 and 2015 were identified from the Surveillance, Epidemiology, and End Results database. Overall survival (OS) and cervical cancer-specific survival (CCSS) were compared among patients who underwent different types of surgery (simple hysterectomy VS radical hysterectomy, lymphadenectomy VS without lymphadenectomy). The Cox proportional hazards regression model was applied to evaluate multiple prognostic factors.

RESULTS

1343 patients were included in this study. The overall incidence of positive nodes in stage IA2 was 2.53%. For well-differentiated IA2 cervical cancer, the incidence of regional lymph node involvement was as low as 1.42%. Compared with patients who underwent lymphadenectomy, the patients who did not undergo lymphadenectomy had the same OS (HR, 1.336; 95% CI, 0.923 to 1.933; P = 0.149) and CCSS (HR, 1.038; 95% CI, 0.504 to 2.140; P = 0.920). The log-rank test also indicated that simple hysterectomy was not associated with decreased OS (HR, 1.048; 95% CI, 0.750 to 1.466; P = 0.781) and CCSS (HR, 1.259; 95% CI, 0.655 to 2.420; P = 0.490). Multivariable analyses showed that lymphadenectomy and type of hysterectomy were not independent predictors of survival for patients with stage IA2 cervical cancer.

CONCLUSIONS

The incidence of nodal involvement in well-differentiated stage IA2 cervical cancer was fairly low, lymphadenectomy may be omitted in these patients. The excision range of parametrial tissue was not associated with the oncological survival of women with stage IA2 cervical cancer, simple hysterectomy may be an appropriate alternative for this group of patients.

Postoperative interventions for preventing bladder dysfunction after radical hysterectomy in women with early-stage cervical cancer

BACKGROUND

Bladder dysfunction is a common complication following radical hysterectomy, caused by the damage to pelvic autonomic nerves that innervate the muscles of the bladder, urethral sphincter, and pelvic floor fasciae. Bladder dysfunction increases the rates of urinary tract infection, hospital visits or admission, and patient dissatisfaction. In addition, bladder dysfunction can also negatively impact patient quality of life (QoL). Several postoperative interventions have been proposed to prevent bladder dysfunction following radical hysterectomy. To our knowledge, there has been no systematic review evaluating the effectiveness and safety of these interventions for preventing bladder dysfunction following radical hysterectomy in women with cervical cancer.

OBJECTIVES

To evaluate the effectiveness and safety of postoperative interventions for preventing bladder dysfunction following radical hysterectomy in women with early-stage cervical cancer (stage IA2 to IIA2).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to April week 2, 2020), and Embase via Ovid (1980 to 2020, week 16). We also checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effectiveness and safety of any type of postoperative interventions for preventing bladder dysfunction following a radical hysterectomy in women with stage IA2 to IIA2 cervical cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgments on the quality and certainty of the evidence. We resolved any disagreements through discussion or consultation with a third review author. Outcomes of interest consisted of spontaneous voiding recovery one week after the operation, quality of life (QoL), adverse events, post-void residual urine volume one month after the operation, urinary tract infection over the one month following the operation, and subjective urinary symptoms.

MAIN RESULTS

We identified 1464 records as a result of the search (excluding duplicates). Of the 20 records that potentially met the review criteria, we included five reports of four studies. Most of the studies had unclear risks of selection and reporting biases. Of the four studies, one compared bethanechol versus placebo and three studies compared suprapubic catheterisation with intermittent self-catheterisation. We identified two ongoing studies. Bethanechol versus placebo The study reported no information on the rate of spontaneous voiding recovery at one week following the operation, QoL, adverse events, urinary tract infection in the first month after surgery, and subjective urinary symptoms for this comparison. The volume of post-void residual urine, assessed at one month after surgery, among women receiving bethanechol was lower than those in the placebo group (mean difference (MD) -37.4 mL, 95% confidence interval (CI) -60.35 to -14.45; one study, 39 participants; very-low certainty evidence). Suprapubic catheterisation versus intermittent self-catheterisation The studies reported no information on the rate of spontaneous voiding recovery at one week and post-void residual urine volume at one month following the operation for this comparison. There was no difference in risks of acute complication (risk ratio (RR) 0.77, 95% CI 0.24 to 2.49; one study, 71 participants; very low certainty evidence) and urinary tract infections during the first month after surgery (RR 0.77, 95% CI 0.53 to 1.13; two studies, 95 participants; very- low certainty evidence) between participants who underwent suprapubic catheterisation and those who underwent intermittent self-catheterisation. Available data were insufficient to calculate the relative measures of the effect of interventions on QoL and subjective urinary symptoms.

AUTHORS' CONCLUSIONS

None of the included studies reported rate of spontaneous voiding recovery one week after surgery, time to a post-void residual volume of urine of 50 mL or less, or post-void residual urine volume at 6 and 12 months after surgery, all of which are important outcomes for assessing postoperative bladder dysfunction. Limited evidence suggested that bethanechol may minimise the risk of bladder dysfunction after radical hysterectomy by lowering post-void residual urine volume. The certainty of this evidence, however, was very low. The effectiveness of different types of postoperative urinary catheterisation (suprapubic and intermittent self-catheterisation) remain unproven.

Morbidity after surgical management of cervical cancer in low and middle income countries: A systematic review and meta-analysis

OBJECTIVE

To investigate morbidity for patients after the primary surgical management of cervical cancer in low and middle-income countries (LMIC).

METHODS

The Pubmed, Cochrane, the Cochrane Central Register of Controlled Trials, Embase, LILACS and CINAHL were searched for published studies from 1st Jan 2000 to 30th June 2017 reporting outcomes of surgical management of cervical cancer in LMIC. Random-effects meta-analytical models were used to calculate pooled estimates of surgical complications including blood transfusions, ureteric, bladder, bowel, vascular and nerve injury, fistulae and thromboembolic events. Secondary outcomes included five-year progression free (PFS) and overall survival (OS).

FINDINGS

Data were available for 46 studies, including 10,847 patients from 11 middle income countries. Pooled estimates were: blood transfusion 29% (95%CI 0.19-0.41, P = 0.00, I2 = 97.81), nerve injury 1% (95%CI 0.00-0.03, I2 77.80, P = 0.00), bowel injury, 0.5% (95%CI 0.01-0.01, I2 = 0.00, P = 0.77), bladder injury 1% (95%CI 0.01-0.02, P = 0.10, I2 = 32.2), ureteric injury 1% (95%CI 0.01-0.01, I2 0.00, P = 0.64), vascular injury 2% (95% CI 0.01-0.03, I2 60.22, P = 0.00), fistula 2% (95%CI 0.01-0.03, I2 = 77.32, P = 0.00,), pulmonary embolism 0.4% (95%CI 0.00-0.01, I2 26.69, P = 0.25), and infection 8% (95%CI 0.04-0.12, I2 95.72, P = 0.00). 5-year PFS was 83% for laparotomy, 84% for laparoscopy and OS was 85% for laparotomy cases and 80% for laparoscopy.

CONCLUSION

This is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in LMIC, which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation.

Nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa)

BACKGROUND

Radical hysterectomy is one of the standard treatments for stage Ia2 to IIa cervical cancer. Bladder dysfunction caused by disruption of the pelvic autonomic nerves is a common complication following standard radical hysterectomy and can affect quality of life significantly. Nerve-sparing radical hysterectomy is a modified radical hysterectomy, developed to permit resection of oncologically relevant tissues surrounding the cervical lesion, while preserving the pelvic autonomic nerves.

OBJECTIVES

To evaluate the benefits and harms of nerve-sparing radical hysterectomy in women with stage Ia2 to IIa cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid (1946 to May week 2, 2018), and Embase via Ovid (1980 to 2018, week 21). We also checked registers of clinical trials, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the efficacy and safety of nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa).

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodology for data collection and analysis. Two review authors independently selected potentially relevant RCTs, extracted data, evaluated risk of bias of the included studies, compared results and resolved disagreements by discussion or consultation with a third review author, and assessed the certainty of evidence.

MAIN RESULTS

We identified 1332 records as a result of the search (excluding duplicates). Of the 26 studies that potentially met the review criteria, we included four studies involving 205 women; most of the trials had unclear risks of bias. We identified one ongoing trial.The analysis of overall survival was not feasible, as there were no deaths reported among women allocated to standard radical hysterectomy. However, there were two deaths in among women allocated to the nerve-sparing technique. None of the included studies reported rates of intermittent self-catheterisation over one month following surgery. We could not analyse the relative effect of the two surgical techniques on quality of life due to inconsistent data reported. Nerve-sparing radical hysterectomy reduced postoperative bladder dysfunctions in terms of a shorter time to postvoid residual volume of urine ≤ 50 mL (mean difference (MD) -13.21 days; 95% confidence interval (CI) -24.02 to -2.41; 111 women; 2 studies; low-certainty evidence) and lower volume of postvoid residual urine measured one month following operation (MD -9.59 days; 95% CI -16.28 to -2.90; 58 women; 2 study; low-certainty evidence). There were no clear differences in terms of perioperative complications (RR 0.55; 95% CI 0.24 to 1.26; 180 women; 3 studies; low-certainty evidence) and disease-free survival (HR 0.63; 95% CI 0.00 to 106.95; 86 women; one study; very low-certainty evidence) between the comparison groups.

AUTHORS' CONCLUSIONS

Nerve-sparing radical hysterectomy may lessen the risk of postoperative bladder dysfunction compared to the standard technique, but the certainty of this evidence is low. The very low-certainty evidence for disease-free survival and lack of information for overall survival indicate that the oncological safety of nerve-sparing radical hysterectomy for women with early stage cervical cancer remains unclear. Further large, high-quality RCTs are required to determine, if clinically meaningful differences of survival exist between these two surgical treatments.

Extended-field radiotherapy for locally advanced cervical cancer

BACKGROUND

The para-aortic lymph nodes (located along the major vessels in the mid and upper abdomen) are a common place for disease recurrence after treatment for locally advanced cervical cancer. The para-aortic area is not covered by standard pelvic radiotherapy fields and so treatment to the pelvis alone is inadequate for women at a high risk of occult cancer within para-aortic lymph nodes. Extended-field radiotherapy (RT) widens the pelvic RT field to include the para-aortic lymph node area. Extended-field RT may improve outcomes in women with locally advanced cervical cancer by treating occult disease in para-aortic nodes not identified at pretreatment imaging. However, RT treatment of the para-aortic area can cause severe adverse effects, so may increase harms.Studies of pelvic chemoradiotherapy (CRT) demonstrated improved survival rates compared to pelvic RT alone. CRT is now the standard of care in the treatment of locally advanced cervical cancer. Studies comparing pelvic RT alone (without concurrent chemotherapy) with extended-field RT should therefore be viewed with caution, since they compare treatments against what is now substandard treatment (pelvic RT alone). This review should therefore be read with this in mind and comparisons with pelvic RT cannot be extrapolated to pelvic CRT.

OBJECTIVES

To evaluate the effectiveness and toxicity of extended-field radiotherapy in women undergoing first-line treatment for locally advanced cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 7), MEDLINE via Ovid (1946 to August week 4, 2018), and Embase via Ovid (1980 to 2018, week 35). We checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies to August 2018.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effectiveness and toxicity of extended-field RT for locally advanced cervical cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgements on the quality and certainty of the evidence for each outcome. Any disagreements were resolved by discussion or consultation with a third review author.

MAIN RESULTS

Five studies met the inclusion criteria. Three included studies compared extended-field RT versus pelvic RT, one included study compared extended-field RT with pelvic CRT, and one study compared extended-field CRT versus pelvic CRT.Extended-field radiotherapy versus pelvic radiotherapy aloneCompared to pelvic RT, extended-field RT probably reduces the risk of death (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.48 to 0.94; 1 study; 337 participants; moderate-certainty evidence) and para-aortic lymph node recurrence (risk ratio (RR) 0.36, 95% CI 0.18 to 0.70; 2 studies; 477 participants; moderate-certainty evidence), although there may or may not have been improvement in the risk of disease progression (HR 0.92, 95% CI 0.69 to 1.22; 1 study; 337 participants; moderate-certainty evidence) and severe adverse events (RR 1.05, 95% CI 0.79 to 1.41; 2 studies; 776 participants; moderate-certainty evidence).Extended-field radiotherapy versus pelvic chemoradiotherapyIn a comparison of extended-field RT versus pelvic CRT, women given pelvic CRT probably had a lower risk of death (HR 0.50, 95% CI 0.39 to 0.64; 1 study; 389 participants; moderate-certainty evidence) and disease progression (HR 0.52, 95% CI 0.37 to 0.72; 1 study; 389 participants; moderate-certainty evidence). Participants given extended-field RT may or may not have had a lower risk of para-aortic lymph node recurrence (HR 0.44, 95% CI 0.20 to 0.99; 1 study; 389 participants; low-certainty evidence) and acute severe adverse events (RR 0.05, 95% CI 0.02 to 0.11; 1 study; 388 participants; moderate-certainty evidence). There were no clear differences in terms of late severe adverse events among the comparison groups (RR 1.06, 95% CI 0.69 to 1.62; 1 study; 386 participants; moderate-certainty evidence).Extended-field chemoradiotherapy versus pelvic chemoradiotherapyVery low-certainty evidence obtained from one small study (74 participants) showed that, compared to pelvic CRT, extended-field CRT may or may not have reduced risk of death (HR 0.37, 95% CI 0.14 to 0.96) and disease progression (HR 0.25, 95% CI 0.07 to 0.87). There were no clear differences between the groups in the risks of para-aortic lymph node recurrence (RR 0.19, 95% CI 0.02 to 1.54; very low-certainty evidence) and severe adverse events (acute: RR 0.95, 95% CI 0.20 to 4.39; late: RR 0.95, 95% CI 0.06 to 14.59; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that, compared with pelvic RT alone, extended-field RT probably improves overall survival and reduces risk of para-aortic lymph node recurrence. However, pelvic RT alone would now be considered substandard treatment, so this result cannot be extrapolated to modern standards of care. Low- to moderate-certainty evidence suggests that pelvic CRT may increase overall and progression-free survival compared to extended-field RT, although there may or may not be a higher rate of para-aortic recurrence and acute adverse events. Extended-field CRT versus pelvic CRT may improve overall or progression-free survival, but these findings should be interpreted with caution due to very low-certainty evidence.High-quality RCTs, comparing modern treatment techniques in CRT, are needed to more fully inform treatment for locally advanced cervical cancer without obvious para-aortic node involvement.

Early-stage node negative cervical adenocarcinoma and squamous cell carcinoma show similar survival outcomes after hysterectomy: a population-based study

OBJECTIVE

To investigate the clinicopathological features and outcomes between node-negative, early-stage cervical squamous cell carcinoma (SCC) and adenocarcinoma (AC) after hysterectomy.

METHODS

Patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stages I-IIA cervical SCC and AC between 1988 and 2013 were retrospectively reviewed using the Surveillance, Epidemiology, and End Results database. We used propensity score-matching to balance patient baseline characteristics. Univariate and multivariate Cox regression analyses were used for prognostic analyses of cause-specific survival (CSS) and overall survival (OS).

RESULTS

A total of 9,858 patients were identified, comprising 6,117 patients (62.1%) and 3,741 (37.9%) patients with cervical SCC and AC, respectively. Compared with cervical SCC, cervical AC cases were more likely to be younger, diagnosed after 2000, white, and have well-differentiated and FIGO stage IB1 disease. For SCC and AC, the 10-year CSS rates were 93.4% and 94.7%, respectively (p=0.011), and the 10-year OS rates were 89.6% and 92.2%, respectively (p<0.001). Multivariate analysis revealed that age, ethnicity, tumor grade, and FIGO stage were independent prognostic factors of CSS and OS, but that histologic subtype was not associated with CSS and OS. In the propensity score-matched patient population, univariate and multivariate analyses also showed that histologic subtype was not associated with survival outcomes.

CONCLUSION

Cervical AC has equivalent survival to cervical SCC in node-negative, early-stage disease after hysterectomy and lymphadenectomy.

Evolution of radical hysterectomy for cervical cancer along the last two decades: single institution experience

Background:

The radical hysterectomy (RH) surgical technique has improved along the years. It is used for the treatment of cervical cancer, endometrial cancer when affecting the cervix, and upper vaginal carcinomas. Our aim was to describe the historical evolution of the technique after the introduction of laparoscopy at our institution.

Methods:

We performed a retrospective review of medical records of patients who underwent RH, grouped in three periods according to the year of surgery: 1990-1999, 2000-2009 and 2010-2013. Patients?characteristics, pathologic details, intraoperative and postoperative complications were analyzed and compared throughout the time periods.

Results:

A total of 102 cases of RH were performed at our center during the study period. Among all data collected, the presence of necrosis, age, number of lymph nodes, surgery route, operating time, hospital stay, blood loss and transfusion requirement were statistically significant different among groups. Conversion to laparotomy rate was 19% for the second period compared to the absence of cases in the last one. No significant differences (P=0.124) were observed in the adjuvant treatment received among the three different groups. At the time of the last contact the patients free of disease were 12 (85.7%), 53 (91.3%) and 26 (86.6%) respectively (P=0.406). Regarding the disease-free interval, we found significant better outcomes in the group of laparotomy compared to laparoscopy (P=0.015).

Conclusions:

Laparoscopic RH is an acceptable surgery with advantages like magnified vision of the operation抯 field, lower surgical complications, shorter hospital stay and earlier resumption to daily activities.

Deep obturator lymph node dissection in gynaecological cancer patients: Is it feasible and useful?

Our aim was to investigate the feasibility and outcomes of deep obturator lymph node (DOLN) dissection in gynaecological cancer patients. A prospective study included 62 patients with a diagnosis of ovarian, endometrial or cervical cancer who underwent surgery. In the study group, 36 patients underwent obturator lymph node dissection above and under the obturator nerve, while 26 control group patients underwent routine obturator lymph node dissection above the obturator nerve. Groups were compared with respect to dissected lymph node count, intraoperative characteristics and early postoperative complications. Total lymph node count in the DOLN dissected group was greater than that in the control group, and the difference was statistically significant. No statistically significant difference was found between the groups, regarding postoperative complications and intraoperative characteristics. The total number of lymph nodes dissected by using DOLN dissection increased without an increase in intra- and postoperative complications in gynaecological cancer patients.