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Nitecki R, Ramirez PT, Dundr P, Nemejcova K, Ribeiro R, Vieira Gomes MT, Schmidt RL, Bedoya L, Isla DO, Pareja R, Rendón Pereira GJ, Lopez A, Kushner D, Cibula D. MILACC study: could undetected lymph node micrometastases have impacted recurrence rate in the LACC trial? Int J Gynecol Cancer 2023; 33:1684-1689. [PMID: 37652529 DOI: 10.1136/ijgc-2023-004711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVE The etiology of inferior oncologic outcomes associated with minimally invasive surgery for early-stage cervical cancer remains unknown. Manipulation of lymph nodes with previously unrecognized low-volume disease might explain this finding. We re-analyzed lymph nodes by pathologic ultrastaging in node-negative patients who recurred in the LACC (Laparoscopic Approach to Cervical Cancer) trial. METHODS Included patients were drawn from the LACC trial database, had negative lymph nodes on routine pathologic evaluation, and recurred to the abdomen and/or pelvis. Patients without recurrence or without available lymph node tissue were excluded. Paraffin tissue blocks and slides from all lymph nodes removed by lymphadenectomy were re-analyzed per standard ultrastaging protocol aimed at the detection of micrometastases (>0.2 mm and ≤2 mm) and isolated tumor cells (clusters up to 0.2 mm or <200 cells). RESULTS The study included 20 patients with median age of 42 (range 30-68) years. Most patients were randomized to minimally invasive surgery (90%), had squamous cell carcinoma (65%), FIGO 2009 stage 1B1 (95%), grade 2 (60%) disease, had no adjuvant treatment (75%), and had a single site of recurrence (55%), most commonly at the vaginal cuff (45%). Only one patient had pelvic sidewall recurrence in the absence of other disease sites. The median number of lymph nodes analyzed per patient was 18.5 (range 4-32) for a total of 412 lymph nodes. A total of 621 series and 1242 slides were reviewed centrally by the ultrastaging protocol. No metastatic disease of any size was found in any lymph node. CONCLUSIONS There were no lymph node low-volume metastases among patients with initially negative lymph nodes who recurred in the LACC trial. Therefore, it is unlikely that manipulation of lymph nodes containing clinically undetected metastases is the underlying cause of the higher local recurrence risk in the minimally invasive arm of the LACC trial.
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Affiliation(s)
- Roni Nitecki
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
| | - Pavel Dundr
- Pathology, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Kristyna Nemejcova
- Pathology, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Reitan Ribeiro
- Surgery, Hospital Erasto Gaertner, Curitiba, Hospital, Brazil
| | | | | | - Lucio Bedoya
- Gynecologic Oncology, Hospital Misercordia, Cordoba, Argentina
| | - David Ortiz Isla
- Gynecologic Oncology, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Rene Pareja
- Gynecologic Oncology, Clinica Astorga, Medellin, and Instituto Nacional de Cancerología, Bogotá, Medellin, Colombia
| | | | - Aldo Lopez
- Gynecologic Surgery, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - David Kushner
- Gynecologic Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David Cibula
- Obstetrics and Gynecology, University of Prague, Prague, Czech Republic
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Rodriguez J, Rauh-Hain JA, Saenz J, Isla DO, Rendon Pereira GJ, Odetto D, Martinelli F, Villoslada V, Zapardiel I, Trujillo LM, Perez M, Hernandez M, Saadi JM, Raspagliesi F, Valdivia H, Siegrist J, Fu S, Hernandez Nava M, Echeverry L, Noll F, Ditto A, Lopez A, Hernandez A, Pareja R. Oncological outcomes of laparoscopic radical hysterectomy versus radical abdominal hysterectomy in patients with early-stage cervical cancer: a multicenter analysis. Int J Gynecol Cancer 2021; 31:504-511. [PMID: 33504547 DOI: 10.1136/ijgc-2020-002086] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/10/2021] [Accepted: 01/13/2021] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Recent evidence has shown adverse oncological outcomes when minimally invasive surgery is used in early-stage cervical cancer. The objective of this study was to compare disease-free survival in patients that had undergone radical hysterectomy and pelvic lymphadenectomy, either by laparoscopy or laparotomy. METHODS We performed a multicenter, retrospective cohort study of patients with cervical cancer stage IA1 with lymph-vascular invasion, IA2, and IB1 (FIGO 2009 classification), between January 1, 2006 to December 31, 2017, at seven cancer centers from six countries. We included squamous, adenocarcinoma, and adenosquamous histologies. We used an inverse probability of treatment weighting based on propensity score to construct a weighted cohort of women, including predictor variables selected a priori with the possibility of confounding the relationship between the surgical approach and survival. We estimated the HR for all-cause mortality after radical hysterectomy with weighted Cox proportional hazard models. RESULTS A total of 1379 patients were included in the final analysis, with 681 (49.4%) operated by laparoscopy and 698 (50.6%) by laparotomy. There were no differences regarding the surgical approach in the rates of positive vaginal margins, deep stromal invasion, and lymphovascular space invasion. Median follow-up was 52.1 months (range, 0.8-201.2) in the laparoscopic group and 52.6 months (range, 0.4-166.6) in the laparotomy group. Women who underwent laparoscopic radical hysterectomy had a lower rate of disease-free survival compared with the laparotomy group (4-year rate, 88.7% vs 93.0%; HR for recurrence or death from cervical cancer 1.64; 95% CI 1.09-2.46; P=0.02). In sensitivity analyzes, after adjustment for adjuvant treatment, radical hysterectomy by laparoscopy compared with laparotomy was associated with increased hazards of recurrence or death from cervical cancer (HR 1.7; 95% CI 1.13 to 2.57; P=0.01) and death for any cause (HR 2.14; 95% CI 1.05-4.37; P=0.03). CONCLUSION In this retrospective multicenter study, laparoscopy was associated with worse disease-free survival, compared to laparotomy.
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Affiliation(s)
- Juliana Rodriguez
- Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia.,Department of Gynecology and Obstetrics, Section of Gynecologic Oncology, Fundacion Santa Fe de Bogota, Bogota, Colombia
| | - Jose Alejandro Rauh-Hain
- Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - James Saenz
- Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia
| | - David Ortiz Isla
- Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | | | - Diego Odetto
- Gynecology Oncology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fabio Martinelli
- Department of Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Vladimir Villoslada
- Department of Gynecologic Oncology, Instituto Nacional de Enfermedades Neoplasicas (INEN), Lima, Peru
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit. La Paz University Hospital, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Lina Maria Trujillo
- Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia
| | - Milagros Perez
- Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Marcela Hernandez
- Department of Gynecologic Oncology, Instituto de Cancerologia Las Américas, Medellín, Colombia
| | - Jose Martin Saadi
- Gynecology Oncology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Francesco Raspagliesi
- Department of Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Henry Valdivia
- Department of Gynecologic Oncology, Instituto Nacional de Enfermedades Neoplasicas (INEN), Lima, Peru
| | - Jaime Siegrist
- Gynecologic Oncology Unit. La Paz University Hospital, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Shuangshuang Fu
- Departments of Gynecologic Oncology and Reproductive Medicine and Health Services Research, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Mindy Hernandez Nava
- Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Mexico City, Mexico
| | - Lina Echeverry
- Department of Gynecologic Oncology, Instituto de Cancerologia Las Américas, Medellín, Colombia
| | - Florencia Noll
- Gynecology Oncology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Antonino Ditto
- Department of Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Aldo Lopez
- Department of Gynecologic Oncology, Instituto Nacional de Enfermedades Neoplasicas (INEN), Lima, Peru
| | - Alicia Hernandez
- Gynecologic Oncology Unit. La Paz University Hospital, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Rene Pareja
- Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia .,Gynecologic Oncology, Clinica Astorga, Professor Universidad Pontificia Bolivariana, Medellin, Colombia
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