Minimally Invasive vs Abdominal Radical Hysterectomy for Cervical Cancer

BACKGROUND AND PURPOSE: 

• Ramirez et al. (NEJM, 2018) compared the efficacy of laparoscopic or robot-assisted radical hysterectomy (minimally invasive surgery) and open abdominal radical hysterectomy (open surgery) among women with early-stage cervical cancer

METHODS: 

• Randomized controlled study (RCT) 
  • Women with stage IA1 (lymphovascular invasion), IA2, or IB1 cervical cancer  
  • Histologic subtype of squamous-cell carcinoma, adenocarcinoma, or adenosquamous carcinoma 
• Patients were randomly assigned to undergo 
  • Minimally invasive surgery 
  • Open surgery 
• Primary outcome: Rate of disease-free survival at 4.5 years

RESULTS: 

• Study did not reach enrollment target 
  • Stopped due to safety concerns by monitoring committee due to recurrence in minimally invasive group (see results below) 
• 319 minimally invasive surgery group | 312 open surgery 
  • Mean age: 46.0 years 
  • 91.9% had stage IB1 disease 
• In the minimally invasive group 
  • Laparoscopy: 84.4%  
  • Robot-assisted surgery: 15.6%  
• Two groups were similar with respect to 
  • Histologic subtypes 
  • Rate of lymphovascular invasion 
  • Rates of parametrial and lymph-node involvement 
  • Tumor size 
  • Rate of use of adjuvant therapy 
• Rate of disease-free survival at 4.5 years  
  • Minimally invasive surgery: 86.0%  
  • Open surgery: 96.5%  
  • Difference: −10.6% (95% CI, −16.4 to −4.7) 
• Minimally invasive surgery was associated with  
  • Lower rate (3 year) of disease-free survival  
    • Minimally invasive: 91.2%  
    • Open surgery: 97.1% 
  • Increased risk of disease recurrence or death from cervical cancer 
    • Hazard ratio (HR): 3.74 (95% CI, 1.63 to 8.58) 
  • Lower overall survival (3-year) rate 
    • Minimally invasive: 93.8%  
    • Open surgery: 99.0% 
  • HR for death from any cause: 6.00 (95% CI, 1.77 to 20.30)

CONCLUSION: 

• Compared to open surgery, non-invasive radical surgery for cervical cancer was associated with a lower rate of disease-free survival and overall survival 
• These results were reflected in a recent cohort study in the same issue of NEJM (Melamed et al.) that also compared minimally invasive vs laparotomy for the treatment of cervical cancer 
  • “Adoption of minimally invasive surgery coincided with a decline in the 4-year relative survival rate of 0.8% (95% CI, 0.3 to 1.4) per year (P=0.01 for change of trend)”
• SGO encourages gyn oncologists

…to consider all available data as they counsel individual patients to determine the most appropriate surgical approach. We anticipate additional data to emerge on this important topic.

• GOC also emphasizes the importance of counseling and in addition
  • Recommends that gyn oncologists should “proceed with caution” as the results of these studies “cannot be ignored”
  • Lists strategies that have been suggested including

…placing a suture on the unaffected cervix at the beginning of surgery for easy retrieval and if possible to cover the tumour, using a vaginal vault cup without intrauterine manipulator, performing a colpotomy circumferentially intra-abdominally (rather than across the vagina) or via the vaginal route, and using specimen extraction techniques that mitigate intra-abdominal spillage

Learn More – Primary Sources: 

Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer (Ramirez et al.)

Survival after Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer (Melamed et al.)

Minimally-Invasive Radical Hysterectomy for Cancer of the Cervix: The Perspective of the Society of Gynecologic Oncologists of Canada (GOC)

Notice to SGO Members: Emerging data on the surgical approach for radical hysterectomy in the treatment of women with cervical cancer