Total laparoscopic radical hysterectomy for locally advanced cervical carcinoma (stages IIB, IIA and bulky stages IB) after concurrent chemoradiation therapy: Surgical morbidity and oncological results

doi:10.1016/j.ygyno.2009.05.043

Gynecologic Oncology

Volume 114, Issue 3, September 2009, Pages 404-409

https://doi.org/10.1016/j.ygyno.2009.05.043 Get rights and content

Abstract

Objectives

To evaluate the surgical outcome and the oncologic results of total laparoscopic radical hysterectomy (TLRH) after neoadjuvant chemoradiation therapy (CRT) for locally advanced cervical carcinoma.

Methods

All patients who underwent TLRH after CRT for stages IIB–IIA and bulky IB diseases were reviewed. The control group for this analysis was a cohort of patients treated with abdominal radical hysterectomy (ARH) after CRT for the same stage cancers.

Results

We reviewed 102 patients operated on between 2000 and 2008 (46 TLRH and 56 ARH). Mean age at diagnosis was 44 years, and mean B.M.I was 22.1. There was no difference in tumor characteristics between the two groups. Seven patients in the laparoscopic group required conversion to laparotomy (15%). Mean estimated blood loss (200 vs. 400 mL, p < 0.01) and the median duration of hospital stay (5 vs. 8 days, p < 0.01) were significantly lower in the laparoscopic group. Morbidity rates and urinary complications were reduced in the laparoscopic group (p = 0.04). Local recurrence rates, disease-free and overall survival were comparable in the two groups. Best survival was observed for patients with pathological complete response or microscopic residual disease compared to patients with macroscopic residues (p < 0.01).

Conclusions

Radical hysterectomy after CRT is known to be difficult with significant morbidity rates and remains controversial in comparison to exclusive CRT. TLRH after preoperative CRT is feasible for patients with locally advanced cervical cancer in 85% of the cases. For these patients, TLRH compared with ARH was associated with favorable surgical outcome with comparable oncological results.

Introduction

In the early nineties, total laparoscopic radical hysterectomy (TLRH) was reported for the first time in the treatment of cervical cancer [1], [2], [3]. During the past decade, several retrospective reports have confirmed the feasibility and the safety of this procedure with experienced teams for the management of early stage cancers. Laparoscopy has been reported to decrease blood loss, postoperative morbidity, pain, and hospital stay with similar oncological radicality and survival [4], [5], [6], [7], [8], [9], [10], [11]. These results have not yet been tested by randomized trials, comparing open and laparoscopic radical hysterectomy. However, TLRH has progressively been accepted by gynecologic oncologists for the surgical treatment of early stage cervical cancer.

On the other hand, chemoradiation therapy (CRT) for bulky cervical cancer compared to external radiation therapy alone has demonstrated its effectiveness with improvement of local control and reduction of the rate of distant metastasis [12], [13], [14], [15], [16]. Currently, the presence of concomitant CRT is considered a standard in the therapeutic sequence of these tumors [12]. Some studies suggested that surgery after neoadjuvant treatment could improve local control for bulky tumors especially in the case of persistent disease on the cervix [17], [18], [19]. The interest of surgery after neoadjuvant CRT is therefore discussed and no randomized studies are available as yet to evaluate the impact on survival of completion surgery after CRT [20].

Some reports have mentioned the possibility of performing TLRH for bulky stage IB or stage IIB cervical cancer after neoadjuvant chemotherapy or neoadjuvant CRT [21]. Effects of radiation on tissues could increase the technical difficulties of this intervention. No large series are available thus far to analyze the surgical and oncological results of this approach. The purpose of this study was to evaluate the feasibility, surgical outcome and oncological results observed after TLRH vs. abdominal radical hysterectomy (ARH) after CRT for locally advanced cervical carcinoma.

Section snippets

Patients

All of the patients diagnosed with a cervical cancer and operated on at our institute between January 2000 and March 2008 were recorded. Patients with bulky stage IB, IIA and proximal IIB disease undergoing radical hysterectomy after concomitant CRT were consecutively included in this study. Initial staging was defined according to FIGO criteria and evaluated by clinical pelvic examination and Magnetic Resonance Imaging. Proximal IIB disease was defined by tumor that involved the medial middle

Patients

During the indicated period, 102 patients with locally advanced cervical cancer underwent radical hysterectomy after CRT at our institution and were eligible for inclusion (28 stage IB, 13 stage IIA and 61 stage IIB disease). Forty-six underwent TLRH (group 1) and 56 ARH (group 2). The average age at diagnosis was 44 years [24–74 years] and the average follow-up duration was 31.2 months. A majority of patients had squamous cell carcinoma. There were no differences between the two groups with

Discussion

The management of locally advanced cervical carcinoma is still debated and varies according to countries and medical institutions. Different therapeutic strategies have been reported for these tumors, including radical surgery plus adjuvant radiation with or without chemotherapy [16], exclusive chemoradiation therapy (CRT) [14], [15] and neoadjuvant chemotherapy or CRT followed by surgery [13], [22]. Alternatively, the presence of concomitant CRT in the therapeutic sequence of bulky tumors has

Conflict of interest statement

The authors have no conflicts of interest to declare.

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Minimally invasive surgery (MIS) has many benefits, in the form of reduced postoperative morbidity, improved recovery and reduced inpatient stay. It is imperative, however, when new techniques are adopted, in the context of treating oncology patients, that the oncological efficacy and safety are established rigorously rather than assumed based on first principles. Here we have attempted to provide a comprehensive review of all the contentious and topical themes surrounding the use of MIS in the treatment of endometrial and cervix cancer following a thorough review of the literature. On the topic of endometrial cancer, we cover the role of laparoscopy in both early and advanced disease, together with the role and unique benefits of robotic surgery. The surgical challenge of patients with a raised body mass index and the frail and elderly are discussed and finally the role of sentinel lymph node assessment. For cervical cancer, the role of MIS for staging and primary treatment is covered, together with the interesting and highly specialist topics of fertility-sparing treatment, ovarian transposition and the live birth rate associated with this. We end with a discussion on the evidence surrounding the role of adjuvant hysterectomy following radical chemoradiation and pelvic exenteration for recurrent cervical cancer. MIS is the standard of care for endometrial cancer. The future of MIS for cervix cancer, however, remains uncertain. Current recommendations, based on the available evidence, are that the open approach should be considered the gold standard for the surgical management of early cervical cancer and that MIS should only be adopted in the context of research. Careful counselling of patients on the current evidence, discussing in detail the risks and benefits to enable them to make an informed choice, remains paramount.
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To analyze the clinical outcomes and the safety of radiochemotherapy (RCT) and image-guided adaptive brachytherapy (IGABT) and to evaluate the impact of hysterectomy (HT) as completion of treatment for cervical cancer.
145 patients with locally advanced cervical cancer were treated at our institution. Patients underwent RCT and IGABT, then hysterectomy (HT) as completion of treatment was performed, with the exception of patients with surgical contraindications, para aortic metastatic disease or patients who refused surgery. Clinical outcomes and morbidity were retrospectively reviewed in both groups. Local relapse free survival (LRFS), pelvic relapse free survival (PRFS) and overall survival (OS) were analyzed.
Completion HT was performed in 90 (62.1%) patients. Complete histological response and microscopic disease were found in 77 patients (85.6%). Local relapse was observed in 14 patients (9.6%) without differences between completion HT group and the definitive RCT and IGABT group (Odds Ratio OR = 1.73 [0.57–5.23], p = 0.33). The estimated 3-year LRFS and PRFS for the entire population were respectively 90% [84%–94%] and 93% [87%–96%], with no significant differences between them (respectively Hazard Ratio HR = 0.57 [0.20–1.64], p = 0.30 and HR = 0.37 [0.10–1.31], p = 0.12). The estimated 3-year OS rate for the whole population was 84% [75%–91%] with no significant differences between groups (HR = 0.81 [0.32–2.06], p = 0.65). Regarding morbidity, grade ≥ 2 vaginal toxicity was more frequent in the definitive RCT and IGABT group (43.6% vs 26.7%, p = 0.04). All grade 4 toxicity events were reported in the completion HT group.
Due to high severe toxicity, RCT and IGABT with dose escalation followed by completion hysterectomy don't seem compatible. No benefit and increased severe late morbidity were observed. Combined intracavitary/interstitial technique is mandatory in large target volume at brachytherapy.
Multimodal treatment including hysterectomy improves survival in patients with locally advanced cervical cancer: A population-based, propensity score–matched analysis
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To evaluate the therapeutic value of multimodal treatment including hysterectomy in locally advanced cervical squamous cell carcinoma (SCC).
We retrospectively reviewed patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IIB–III cervical SCC and received chemotherapy and radiotherapy with or without hysterectomy between 2000 and 2013 using the Surveillance, Epidemiology, and End Results program. Propensity score-matching was used to balance baseline characteristics of included patients. Univariate and multivariate Cox regression analyses were performed to determine prognostic factors for cervical cancer specific-survival (CCSS) and overall survival (OS).
We identified 2473 patients and 522 pairs of patients were completely matched with each other. In the unmatched population, patients with younger age, non-black race, poorly/undifferentiated disease, FIGO stage IIB disease, and node-positive disease were more likely to receive additional hysterectomy. Additional hysterectomy was associated with better CCSS and OS in unmatched and matched populations. Moreover, when evaluating the survival difference by FIGO stage, only stage IIB disease retained statistical significance but not for stage III disease in unmatched and matched populations.
Our results suggest that multimodal treatment including hysterectomy might improve survival outcomes in patients with locally advanced cervical SCC, especially for stage IIB disease.
Robotic Radical Hysterectomy After Concomitant Chemoradiation in Locally Advanced Cervical Cancer: A Prospective Phase II Study
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To assess the feasibility of total robotic radical surgery (TRRS) in patients with locally advanced cervical cancer (LACC) who receive chemoradiation therapy (CT/RT).
A prospective (preplanned) study of a nonrandomized controlled trial (Canadian Task Force classification level 2).
Catholic University of the Sacred Hearth, Rome, Italy.
Between September 2013 and January 2016, a total of 40 patients with LACC (Fédération Internationale de Gynécologie et d'Obstétrique stage IB2–III) were enrolled in the study.
Robotic radical hysterectomy (RRH) plus pelvic and/or aortic lymphadenectomy was attempted within 6 weeks after CT/RT. The feasibility of TRRS as well as the rate, pattern, and severity of early and late postoperative complications were analyzed.
After CT/RT, 29 patients (72.5%) underwent type B2 RRH, and 11 (27.5%) underwent type C1 RRH. Pelvic lymphadenectomy was performed in all cases. TRRS was successful in 39 of 40 cases (feasibility rate = 97.5%). In patients successfully completing TRRS, the median operating time was 185 minutes (range, 100–330 minutes), and the median blood loss was 100 mL (range, 50–300 mL). The median time of hospitalization counted from the first postoperative day was 2 days (range, 1–4 days). No intraoperative complications were recorded. During the observation period (median = 18 months; range, 4–28 months), 9 of 40 (22.5%) experienced postoperative complications, for a total number of 12 complications. As of April 2016, recurrence of disease was documented in 5 cases (12.5%).
TRRS is feasible in LACC patients administered preoperative CT/RT, providing perioperative outcomes comparable with those registered in early-stage disease, and LACC patients receiving neoadjuvant chemotherapy.
Radical hysterectomy after chemoradiation in FIGO stage III cervical cancer patients versus chemoradiation and brachytherapy: Complications and 3-years survival
2016, European Journal of Surgical Oncology
Citation Excerpt :
Conversely, the adoption of three-modality approach has been addressed to potentially increase the complications rate,5 and to reduce all available treatments for the recurrent disease.8–10 Due to the retrospectively design of the studies and to the heterogeneity of sample populations, the role of completion hysterectomy after CT-RT still remains debated.11–14 Indeed, one of the first randomized trial (GYNECO-02) aimed to evaluate the therapeutic efficacy of completion surgery after CT-RT versus observation, was prematurely closed because of poor accrual.8
To compare patterns and rates of early and late complications, and survival outcome in FIGO stage III cervical cancer patients underwent to radical hysterectomy after chemo-radiation (CT-RT) vs. chemo-radiation alone.
Between May 1996 and April 2013 150 FIGO stage III cervical cancer patients were treated. We divide patients according to type of treatment: 77 were submitted to standard treatment (Group A), and 73 to completion hysterectomy after chemo-radiation (Group B).
The baseline characteristics of the 2 groups were superimposable. We observed lower intra-operative and treatment-related early urinary and gastro-intestinal complications in Group B with respect to Group A (p < 0.001). Vascular complications were registered only in Group B (p < 0.001). We found a significantly higher rate of local recurrences in the Group A than in the Group B (p < 0.002). We registered 29 deaths in the Group A and 22 in the Group B (p = 0.021). The 3-years disease-free survival rate in the Group A and in the Group B was 62.9% and 68.3%, respectively (p = 0.686), and the 3-years overall survival rate in the Group A and in the Group B was 63.2% and 67.7%, respectively (p = 0.675).
This study confirms that radical hysterectomy after CT-RT is an effective therapeutic approach for advanced cervical cancer. Further prospective and randomized studies should be performed in order to solve the question about the standard approach, and how the different pattern of complication could impact on the quality of life.
Laparoscopic hysterectomy after concurrent radiochemotherapy in locally advanced cervical cancer compared to laparotomy: A multi institutional prospective pilot study of cost, surgical outcome and quality of life
2016, European Journal of Surgical Oncology
Citation Excerpt :
In the past few years, trends in France are to reduce the length of stay. In France, Colombo PE et al.,24 reported a 5 day hospital stay after laparoscopy versus 8 days for laparotomy. Once the relevant range of costs has been identified, the individual items must be measured and valued.
Laparoscopy allows hysterectomies after chemoradiation to be performed without opening the abdominal wall. We measured the costs and quality of life for locally advanced cervical cancer patients operated on via laparoscopy compared to laparotomy.
We conducted an observational prospective multicenter study on locally advanced cervical cancer patients undergoing an extrafascial hysterectomy after concurrent chemoradiotherapy (CRT). We assessed the costs from the medical visit before surgery up to the first month after surgery from the providers' perspective and measured the quality of life using the EORTC QLQ-C30 and QLQ-CX24 up to six months.
Sixty two patients (39 laparoscopy and 23 laparotomy) from December 2008 to November 2011 were included. There was no difference in operative time, or intraoperative and post-operative complication rates between the two groups. Intraoperative transfusion and abdominal drain were significantly lower in the laparoscopy group (respectively, p = 0.04 and p < 0.01), as well as the duration of hospital stay (7.3 d vs 5.7 d, p < 0.001). All patients who underwent laparoscopic hysterectomy were discharged to home, whereas 4 laparotomy patients used convalescence homes (p = 0.01). Mean costs at one month were €10,991 for laparotomy and €11,267 for laparoscopy (p = 0.76). Sexual activity is better for the laparoscopy group at six months (p = 0.01).
Laparoscopy for an extrafascial hysterectomy after CRT in locally advanced cervical cancer patients brought better quality of life with similar costs compared to laparotomy, and should therefore be the first choice for surgeons.

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Total laparoscopic radical hysterectomy for locally advanced cervical carcinoma (stages IIB, IIA and bulky stages IB) after concurrent chemoradiation therapy: Surgical morbidity and oncological results

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Patients

Discussion

Conflict of interest statement

Am. J. Obstet. Gynecol.

Am. J. Obstet. Gynecol.

Gynecol. Oncol.

Gynecol. Oncol.

J. Minim. Invasive Gynecol.

Gynecol. Oncol.

J. Minim. Invasive Gynecol.

Gynecol. Oncol.

Eur. J. Surg. Oncol.

Lancet

Eur. J. Surg. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.