Minimally Invasive Hysterectomy Shows Inferior Recurrence Rates in Early-Stage Cervical Cancer

Patients with early-stage cervical cancer who undergo minimally invasive radical hysterectomy (RH) have an inferior rate of disease-free survival (DFS) compared to women who undergo open abdominal RH, according to a recent retrospective analysis published in the Journal of Clinical Oncology.

The multi-institutional review reported that of 815 women with stage IA1 (with lymphovascular invasive), IA2, or IB1 squamous, adenocarcinoma, or adenosquamous adenocarcinoma of the cervix, 9.1% experienced recurrence with minimally invasive RH versus 7.5% with the open approach (P = .43).

Notably, neither the unadjusted analysis (HR, 1.14; 95% CI, 0.61-2.11) nor the risk-adjusted analysis (HR, 1.01; 95% CI, 0.50-2.20) demonstrated a significant difference in overall survival between the minimally invasive versus open abdominal approaches.

A risk-adjusted analysis revealed that conization before surgery was associated with a lower risk of recurrence (aHR, 0.4; 95% CI, 0.23-0.71). Specifically, 243 women who underwent prior conization and did not have residual tumor on preoperative assessment before RH recurred at a decreased rate of 1.4% for the open group and 2.9% for the minimally invasive group (P = .48).

There were no recurrences reported in the 222 women who did not have residual tumor following their respective procedures on final pathology. Recurrences occurred in women with tumors ≤2 on final pathology at a rate of 2.4% with open RH and 8.8% with minimally invasive RH. Patients with >2 cm tumors on final pathology recurred at a rate of 14.4% and 16.6%, respectively.

Out of 9 institutions, 1 site did not collect data regarding preoperative tumor size.

“Our results highlight the limitations of clinical evaluation of tumor size in making operative decisions for cervical cancer; nearly one-quarter of the patients categorized as ≤2 cm on preoperative evaluation had tumors > 2 cm on final pathology,” the study authors reported.

Additionally, the risk-adjusted analysis revealed that minimally invasive RH is independently associated with an increased risk of recurrence (aHR, 1.88; 95% CI, 1.04-3.25). Tumor size, disease grade, and adjuvant radiation were also independently associated with greater hazard of recurrence.

Of women included in the final analysis, 29.1% underwent open RH compared to 70.9% who underwent minimally invasive RH. Moreover, robotic-assisted RH was performed in 89.3% of patients in the minimally invasive group, while the remainder received laparoscopic RH.

The cohort demographics were similar between the open and minimally invasive surgical arms; however, African-American women accounted for 9.8% of the minimally invasive RH group compared with 4.7% of the open RH group. Missing grade information also differed between cohorts with 13% versus 4.7%, respectively.

Patients undergoing open RH had a median tumor size of 2 cm, while the median tumor size was 1.3 cm for women undergoing minimally invasive RH. Patients in the open cohort also experienced a longer follow-up to the minimally invasive cohort at 44.6 months compared with 30.7 months, respectively.

While 23.9% of patients in the underwent sentinel lymph node dissection, all patients in this cohort were subject to completion pelvic lymph node dissection. The final lymph node positivity rate was 10.2% in the open RH group and 11.4% in the minimally invasive RH group. The rates of adjuvant treatment prescribed and completed were similar between groups.

A propensity-score matching analysis noted a 4.4% recurrence rate among 159 open cases and 11.5% in 156 matched minimally invasive cases (P = .019). Furthermore, a survival analysis of the matched cases revealed that the risk of recurrence in the minimally invasive group was more than doubled compared with the open group (HR, 2.83; 95% CI, 1.10-7.18).

The propensity-score matching analysis reported that 5 deaths in the open RH cohort and 8 deaths in the minimally invasive RH cohort occurred.

This study confirms other historically established findings that minimally invasive RH is associated with a greater risk of recurrence.

“Two primary differences in these approaches are the use of uterine manipulator and the method of colpotomy,” the authors explained. “Both of these have been implicated in likely exposure of the tumor to the abdominal cavity at the end of the procedure.

This hypothesis is supplemented by the low risk-adjusted recurrence rate in patients who received conization prior to surgery. Additional evidence is that there were no recurrences among patients who did not have residual tumor on the final pathology.

Going forward, additional analyses are needed to look at modification techniques in carefully selected patients.

“Further studies should consider focusing on patients with smaller tumors and potentially containing the tumor spread by using techniques where the tumor is isolated from the abdominal cavity,” the authors concluded. “Given our analysis highlights the discrepancy in determining tumor size clinically, we believe that future studies should strongly consider preoperative size determination by [MRI].”

Uppal S, Gehrig PA, Peng K, et al. Recurrence rates in patients with cervical cancer treated with abdominal versus minimally invasive radical hysterectomy: A multi-institutional retrospective review study. [Published online February 7, 2020]. J Clin Oncol. doi: 10.1200/JCO.19.03012