Surgical treatment of “intermediate risk” lymph node negative cervical cancer patients without adjuvant radiotherapy—A retrospective cohort study and review of the literature

Abstract

Objectives: The role of adjuvant radiotherapy for lymph node-negative stage IB patients with tumor- related negative prognostic factors is not uniformly accepted. It is advocated based on the GOG 92 trial, which was initiated in 1989. The aim of the current study is to report the oncological outcome of “intermediate risk” patients treated by tailored surgery without adjuvant radiotherapy. Data from two institutions that refer these patients for adjuvant radiotherapy served as a control group. Methods: Included were patients with stage IB cervical cancer treated with radical hysterectomy and pelvic lymphadenectomy, who had negative pelvic lymph nodes but a combination of negative prognostic factors adopted from the GOG 92 trial. Data were obtained from prospectively collected databases of three institutions. Radical surgery was a single-treatment modality in one of them and in the remaining two institutes it was followed by adjuvant chemoradiation. Results: In 127 patients who received only radical surgery, with a median follow-up of 6.1 years, the local recurrence rate was 1.6% (2 cases), and total recurrence was 6.3% (8 cases). Disease-specific survival at five years was 95.7% (91.9%; 99.4%) and 91% (83.7%; 98.3%) at 10 years. The only significant factor for disease-specific survival was tumor size ≥4 cm (P=0.032). The recurrence rate, local control or overall survival did not differ from the control group. Adjuvant radiotherapy was not a significant prognostic factor within the whole cohort. Conclusions: An excellent oncological outcome, especially local control, can be achieved by both radical surgery or combined treatment in stage IB lymph node-negative cervical cancer patients with negative prognostic factors. The substantially better outcome than in the GOG 92 trial can be attributed to more accurate pre-operative and pathological staging and an improvement in surgical techniques.

Analysis of isolated loco-regional recurrence rate in intermediate risk early cervical cancer after a type C2 radical hysterectomy without adjuvant radiotherapy

“…Therefore, inadequate surgery might have been the cause of the very high isolated loco-regional recurrence rate of 19.3% found in the surgery-only arm. This is in contrast with the data of the study of Cibula et al, where a type C2 radical hysterectomy was performed in tumors that were >4 cm in diameter, resulting in an isolated local recurrence rate of 1.6% 4. In a recent, large retrospective study, we have shown that radicality of surgery is an independent prognostic factor for recurrence and survival, especially in the group of patients with large tumors (>4 cm) 18.…”

“…Our results in this study confirm the low rate of intermediate risk patients dying from an isolated loco-regional recurrence after a type C2 radical hysterectomy without adjuvant radiotherapy as shown before in a subset of the current study population 6. Recently, other authors reached the same conclusion on the basis of a case–control study, showing isolated loco-regional recurrences in 1.6% vs 0% in the surgery only and adjuvant radiotherapy groups, respectively 4. Our results with 5.6% isolated loco-regional recurrences, compare unfavorably with the data published by Cibula and co-workers, showing 1.6% isolated loco-regional recurrences.…”

“…This lower loco-regional recurrence rate might be due to the exclusion of patients with micrometastases identified after a sentinel lymph node procedure and by using imaging more frequently, resulting in exclusion of patients with extra-uterine disease. Also, only 12% of patients in the Cibula study had a tumor diameter ≥4 cm compared with a clinical tumor diameter ≥4 cm in 65% (105/161) of patients in our population, which might have contributed to their more favorable findings 4. In the follow-up of the original Sedlis study, published in 2006, it was concluded that adjuvant radiotherapy for an intermediate risk group could be particularly beneficial for patients with tumors with non-squamous histology, because in the radiotherapy arm they found that 3 (8.8%) of 34 patients had recurrences vs 11 (44%) of 25 patients in the surgery-only arm 7.…”

“…Recently, a study was published on the role of adjuvant chemoradiotherapy in patients with surgically treated early cervical cancer and intermediate risk factors 4. The authors showed that there was no improvement in loco-regional control, disease specific, or overall, survival for patients treated with adjuvant chemoradiotherapy compared with a group of patients without adjuvant treatment.…”

Comparison of no adjuvant treatment and radiotherapy in early‐stage cervical carcinoma with intermediate risk factors

“…Recently, Cibula et al . published a comparison of results of no adjuvant treatment (NAT) versus adjuvant radiotherapy after radical hysterectomy in these patients and suggested that observation leads to similar overall survival (OS) and disease‐free survival (DFS) with good rates of local control when compared to adjuvant radiation therapy.…”