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No Survival Advantage from Radical Hysterectomy in Patients with Cervical Cancer and Intraoperative Detection of Positive Lymph Node Involvement

Whether women with cervical cancer benefit from completion of radical surgery upon intraoperative determination of N1 positivity had been controversial
22 Sep 2020
Gynaecologic malignancies

No significant difference was observed in the risk of recurrence, local recurrence, or death between patients with cervical cancer in whom radical uterine procedure (mostly radical hysterectomy) was completed or abandoned upon intraoperative detection of a positive pelvic lymph node (LN). These findings from a retrospective observational international ABRAX study were presented by Prof. David Cibula of the Gynaecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic at the ESMO Virtual Congress 2020.

Prof. Cibula discussed the controversy regarding the management of patients with cervical cancer who are diagnosed with positive pelvic LNs intraoperatively. Current clinical practice is almost equally divided between two different types of managements. He noted that extensive surgical dissection in the pelvis followed by pelvic radiotherapy has been related with higher morbidity since both treatment modalities are associated with different types of adverse events.

Prof. Cibula and colleagues conducted the ABRAX study to evaluate whether the completion of radical hysterectomy improves the outcome in these patients.

The ABRAX multicentre, retrospective, cohort study data comprised 515 patients who were referred for primary surgery with a curative intent between 2005 and 2015 for stage IA-IIB tumours and were subsequently found to be LN positive during the surgery. LNs with metastasis ≥0.2 mm were considered positive (N1).

The patients were stratified according to the type of surgical management  into two subgroups: the COMPL group included 361 patients in whom uterine procedure was completed as planned (92.8% radical hysterectomy; 3.9% simple hysterectomy; 2.5% radical trachelectomy; 0.6% simple trachelectomy), and the ABAND group of 154 patients in whom uterine procedure was abandoned based on intraoperative detection of LN positivity. Traditional prognostic markers, such as tumour size, tumour type and disease stage were balanced between the two groups. By propensity score matching, none of the outcome endpoint was influenced by the type of the management after removal of other potentially relevant covariates. Additional treatment administered included adjuvant chemoradiation in 75%, combined radiotherapy in 13% and chemotherapy only in 17% of the COMPL group and primary chemoradiation in 93% and primary combined radiotherapy in 7% of patients in the ABAND group.

With median follow-up of 48.9 months, 381 (74%) patients in the overall population maintained disease free.

No significant difference was found between the two groups regarding the risk of recurrence (hazard ratio [HR] 1.154; p = 0.446), local recurrence (HR 0.836; p = 0.557), or death (HR 1.064; p = 0.779).

Subgroup analyses did not identify a group of patients that showed a survival benefit from completing uterine surgery.

In the overall study cohort, increasing FIGO stage and tumour size ≥4 cm were identified as major prognostic factors that associated with the risk of recurrence and poorer survival.

Conclusions

Based on these results from the ABRAX study, the authors concluded that completion of radical hysterectomy in patients with intraoperative detection of positive LNs does not improve survival, irrespective of tumour size or tumour type.

Therefore, the investigators suggest that, if pelvic LN involvement is diagnosed at surgery, abandonment of planned uterine procedure should be considered and the patient should be referred to definitive chemoradiation.

Funding for this study was reported from the Charles University in Prague (UNCE 204065 and PROGRES Q28/LF1) and the Czech Research Council (No 16-31643A).

Reference

806O – Cibula D, Dostalek L, Hillemanns P, et al. Radical hysterectomy in cervical cancer patients with intraoperatively detected positive lymph node: ABRAX multicentric retrospective cohort study (ENGOT-Cx3/CEEGOG CX2). ESMO Virtual Congress 2020.

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