Recurrence rates in cervical cancer patients treated with abdominal versus minimally invasive radical hysterectomy: A multi-institutional analysis of 700 cases.

Abstract

5504 Background: Compare outcomes between open and minimally invasive radical hysterectomy. Methods: Retrospective multi-institutional review of patients undergoing radical hysterectomy for stage IA1, IA2 and IB1 squamous, adeno- or adeno-squamous carcinoma between 01/01/2010 - 12/31/2017. Results: From 704 cases that met the inclusion criteria, 185 (26.3%) underwent open and 519 (73.7%) underwent minimally invasive surgery (MIS). Women treated with open surgery were older, had larger tumors on preoperative assessment as well as on final pathology assessment, had higher proportion of patients with IB1 stage and adjuvant therapy. Patients undergoing open surgery had longer median follow-up compared to MIS (44 vs. 30.3 months, p < 0.001). The two groups were similar in regard to race distribution, body mass index, comorbidities and preoperative histology. There were 13/185 (7%) recurrences and 10/185 (5.4%) deaths in the open compared to 42/519 (8.1%) recurrences and 26/519 (5%) deaths in MIS (p = n.s for both). However, on multivariate analysis, after controlling for race, comorbidities, preoperative tumor size, histology, grade and smoking status, MIS had higher odds of recurrence (OR 2.24, 95% CI 1.04 - 4.87, p = 0.04). On a second model, in addition to prior mentioned factors, we included lymphovascular space invasion, receipt of adjuvant therapy and vaginal margin status. Undergoing MIS remained associated with higher odds of recurrence (OR 2.37, 95% CI 1.1 - 5.1, p = 0.031). On sub-group analysis of cases with preoperative tumor size less than equal to 2 cm, there were 5/121 (4.1%) recurrence in open and 25/415 (6%) recurrences in MIS group (p = 0.34). Multivariate analysis did not show a higher rate of recurrence in MIS arm in this subgroup. In 26 cases of MIS where no vaginal manipulator was used, no recurrences were noted. In comparison 19/270 (7%) recurrences were noted in intra-uterine manipulator (V-care/Zumi/Rumi) and 22/210 (11%) in vaginal manipulators (EEA sizer/Colpo Probe) groups (p = 0.119). Conclusions: In this large retrospective analysis, patients undergoing MIS for early stage cervical cancer had higher odds of recurrence. In patients with 2 cm or less tumor on preoperative assessment, recurrence rates were similar between the two groups. Role of manipulator in increasing recurrence should be further studied in this patient population.

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer

“…The flaws are dependent on outdated methodology, confounding factors, heterogeneity of reporting of results, lack of replication, and a failure to interpret findings within the limitations of observational research methodology [29][30][31] Overall, the results reflect that in this large European population findings were consistent with recently published prospective data and confirmed by several retrospective population-based analyzes published since the LACC trial. [8][9][10][11][12][13][14][15] There are two prospective randomized trials exploring the role of minimally invasive surgery in patients with cervical cancer. The first is the RACC trial, 28 a Swedish multicentric prospective trial comparing robotic vs open surgery for the treatment of early-stage cervical cancer.…”

“…[4][5][6][7] However, two recent manuscripts published in October of 2018 in NEJM (the LACC trial and a large epidemiologic study involving women from Cancer-Accredited hospitals in the United States) 8 9 demonstrated higher rates of recurrence and death in patients that underwent minimally invasive radical hysterectomy. Subsequently, a number of retrospective studies corroborated these findings, [10][11][12][13][14][15] resulting in a recent modification of the NCCN, European Society of Gynecological Oncology (ESGO), and ESMO guidelines. [16][17][18] The unexpected results of the LACC trial and other retrospective studies led to an ongoing discussion regarding the ideal surgical approach in patients with early cervical cancer.…”

The influence of learning curve of robot‐assisted laparoscopy on oncological outcomes in early‐stage cervical cancer: an observational cohort study

“…The MIS arm of this trial consisted predominately of conventional laparoscopy with only 15.6% of the patients undergoing robot‐assisted surgery. Multiple subsequent observational studies have substantiated these results regarding MIS, 10–13 whereas others reported non‐inferiority of recurrence and survival rates after (specifically) robot‐assisted surgery 14–16 …”

Robotic surgery for gynecologic cancers: indications, techniques and controversies

“…The significance of the 2 cm size cut‐off has also been incorporated in the most updated FIGO cervical cancer staging, suggesting that this tumor size is of oncologic significance . Therefore, given the limited data in patients with small lesions or < 2 cm, among appropriately selected cases, robotically assisted surgery may still be an appropriate option after thorough counseling …”