Comparison of survival outcomes between minimally invasive surgery and conventional open surgery for radical hysterectomy as primary treatment in patients with stage IB1–IIA2 cervical cancer

Highlights

• We investigated survival outcome of radical hysterectomy (RH) by laparoscopic surgery in early-stage cervical cancer.

• Compared to open RH, minimally invasive surgery (MIS) was associated with higher recurrence rates.

• MIS RH was not a poor prognostic factor in patients with stage IB1 and cervical mass size ≤2 cm on pre-operative MRI.

Abstract

Objective

To compare survival outcomes of minimally invasive surgery (MIS) and conventional open surgery for radical hysterectomy (RH) among patients with early-stage cervical cancer (CC).

Methods

We retrospectively identified stage IB1-IIA2 CC patients who underwent either laparoscopic or open Type C RH between 2000 and 2018. Patients' clinicopathologic characteristics and survival outcomes were compared according to the surgical approach. For a more robust statistical analysis, we narrowed the study population down to the patients with stage IB1 who underwent pre-operative MRI.

Results

In total, 435 and 158 patients were assigned to open surgery and MIS groups, respectively. MIS group had significantly less parametrial invasion (6.3% vs. 15.4%; P = 0.004). Despite similar proportions of patients received adjuvant treatment, concurrent chemoradiation therapy was performed less frequently in MIS group. After a median follow up of 114.8 months, the groups showed similar overall survival; however, MIS group displayed poorer progression-free survival (PFS; 5-year rate, 78.5% vs. 89.7%; P < 0.001). Multivariate analyses identified MIS as an independent poor prognostic factor for PFS (adjusted HR, 2.883; 95% CI, 1.711–4.859; P < 0.001). Consistent results were observed among 349 patients with stage IB1: MIS was associated with higher recurrence rates (adjusted HR, 2.276; 95% CI, 1.039–4.986; P = 0.040). However, MIS did not influence PFS of stage IB1 patients with cervical mass size ≤2 cm on pre-operative MRI (adjusted HR, 1.146; 95% CI, 0.278–4.724; P = 0.850).

Conclusions

Overall, MIS RH was associated with higher recurrence rates than open RH in patients with early-stage CC. However, MIS was not a poor prognostic factor among those with stage IB1 and cervical mass size ≤2 cm on pre-operative MRI.

Introduction

Cervical cancer (CC) is the fourth most common cancer in women, accounting for 527,600 new cases and 265,700 deaths each year globally [1]. In 2018, CC is estimated to account for 1.5% (13,240) of new cancer cases among women in the United States [2]. In Korea, although its incidence has been decreasing, CC is still more prevalent than in Western countries and is expected to account for 3.1% (2910) of new cancer cases among women [3,4].

Radical hysterectomy (RH) with bilateral pelvic lymph node dissection is recommended as the standard treatment for early-stage CC [International Federation of Gynecology and Obstetrics (FIGO) stage IB1 or IIA1 disease]. RH accompanied by adjuvant treatment is also a recommended treatment option for bulky tumors in stage IB2 or IIA2 [[5], [6], [7], [8]]. In the era of minimally invasive surgery (MIS), RH is commonly performed by laparoscopic surgery or robot-assisted surgery, both supported by evidence of oncologic safety in real-world clinical practice [[9], [10], [11], [12]].

MIS has been accepted in cancer treatment because compared with conventional laparotomic surgery in patients with various cancer types, it reduces operative morbidity and shortens hospital stays without compromising survival outcomes [[13], [14], [15], [16]]. A recent phase III randomized trial in patients with CC, named as the “Laparoscopic Approach to Carcinoma of the Cervix (LACC) trial,” reported discouraging results, however: patients that underwent MIS for RH had higher recurrence rates and worse overall survival compared with patients that underwent open surgery for RH [17].

There are some controversies surrounding the LACC trial. For example, the recurrence rate was low compared with that in other studies, probably because of a short follow-up period, and the proficiency of the surgeons performing the MIS has been questioned [[18], [19], [20], [21]]. In addition, confirmation studies that consider the medical circumstances of different countries are warranted. Furthermore, subgroup analyses to identify specific patients for whom MIS might entail an especially low risk would be very important in real-world practice.

Thus, we aimed to compare the survival outcomes of RH performed by MIS and open surgery, respectively, in patients with FIGO stage IB1–IIA2 CC at a high-volume tertiary institutional hospital in Korea. We also investigated prognostic factors that might affect survival outcomes in those patients.