Meeting NewsPerspective

Minimally invasive surgery linked to higher recurrence risk in early cervical cancer

Shitanshu Uppal, MBBS
Shitanshu Uppal

CHICAGO — Women who underwent minimally invasive surgery for early-stage cervical cancer demonstrated higher odds of recurrence than women who underwent open surgery, according to results of a multicenter retrospective study presented at ASCO Annual Meeting.

Results showed similar recurrence rates in both surgery groups among women with tumors 2 cm or smaller on preoperative assessment.

“[This study] includes majority robotic surgery cases, [was conducted] at eight high-volume academic institutions [and had] detailed pathologic and follow-up data,” Shitanshu Uppal, MBBS, associate professor and obstetrician-gynecologist at University of Michigan, said during the presentation. “Future randomized studies should consider technique modification.”

The study by Uppal and colleagues included 704 women who underwent radical hysterectomy with open surgery (26.3%, n = 185) or minimally invasive surgery (73.7%, n = 519) for stage IA1, IA2 and IB1 squamous, adeno- or adeno-squamous carcinoma between 2010 and 2017.

Women treated with open surgery tended to be older and had larger tumors and longer median follow-up (44 months vs. 30.3 months, P < .001) than women who received minimally invasive surgery.

The two groups had similar characteristics in terms of race, BMI, comorbidities and preoperative histology.

Results showed 13 recurrences (7%) and 10 deaths (5.4%) in the open surgery group compared with 42 recurrences (8.1%) and 26 deaths (5%) in the minimally invasive group.

A multivariate analysis that controlled for race, comorbidities, preoperative tumor size, histology, grade and smoking status showed higher odds of recurrence with minimally invasive surgery compared with open surgery (OR = 2.24; 95% CI, 1.04-4.87).

A second model that added lymphovascular space invasion, receipt of adjuvant therapy, and vaginal margin status as control factors also found minimally invasive surgery associated with higher odds of recurrence than open surgery (OR = 2.37; 95% CI, 1.1-5.1).

In a subgroup analysis of cases with preoperative tumor sizes smaller than or equal to 2 cm, five women in the open surgery group (4.1%) had recurrences compared with 25 women in the minimally invasive group (6%). A multivariate analysis of this subgroup did not show higher odds of recurrence in the minimally invasive group.

Researchers observed no recurrences in 26 cases of minimally invasive surgery where no vaginal manipulator was used.

However, there were 19 recurrences (7%) in cases where an intra-uterine manipulator was used and 22 recurrences (11%) in cases where a vaginal manipulator was used.

Researchers suggested further investigation of the manipulator’s role in increasing recurrence.

“The question is, where do we go from here? ... [We have to decide] if this is a fight worth fighting,” Uppal said. Whether [minimally invasive] hysterectomies should continue is up for debate. There are going to be some big questions about the cervical cancer centralization of care.” – by John DeRosier

Reference:

Uppal S, et al. Abstract 5504. Presented at: ASCO Annual Meeting; May 31-June 4, 2019; Chicago.

Disclosures: Uppal reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.

Shitanshu Uppal, MBBS
Shitanshu Uppal

CHICAGO — Women who underwent minimally invasive surgery for early-stage cervical cancer demonstrated higher odds of recurrence than women who underwent open surgery, according to results of a multicenter retrospective study presented at ASCO Annual Meeting.

Results showed similar recurrence rates in both surgery groups among women with tumors 2 cm or smaller on preoperative assessment.

“[This study] includes majority robotic surgery cases, [was conducted] at eight high-volume academic institutions [and had] detailed pathologic and follow-up data,” Shitanshu Uppal, MBBS, associate professor and obstetrician-gynecologist at University of Michigan, said during the presentation. “Future randomized studies should consider technique modification.”

The study by Uppal and colleagues included 704 women who underwent radical hysterectomy with open surgery (26.3%, n = 185) or minimally invasive surgery (73.7%, n = 519) for stage IA1, IA2 and IB1 squamous, adeno- or adeno-squamous carcinoma between 2010 and 2017.

Women treated with open surgery tended to be older and had larger tumors and longer median follow-up (44 months vs. 30.3 months, P < .001) than women who received minimally invasive surgery.

The two groups had similar characteristics in terms of race, BMI, comorbidities and preoperative histology.

Results showed 13 recurrences (7%) and 10 deaths (5.4%) in the open surgery group compared with 42 recurrences (8.1%) and 26 deaths (5%) in the minimally invasive group.

A multivariate analysis that controlled for race, comorbidities, preoperative tumor size, histology, grade and smoking status showed higher odds of recurrence with minimally invasive surgery compared with open surgery (OR = 2.24; 95% CI, 1.04-4.87).

A second model that added lymphovascular space invasion, receipt of adjuvant therapy, and vaginal margin status as control factors also found minimally invasive surgery associated with higher odds of recurrence than open surgery (OR = 2.37; 95% CI, 1.1-5.1).

In a subgroup analysis of cases with preoperative tumor sizes smaller than or equal to 2 cm, five women in the open surgery group (4.1%) had recurrences compared with 25 women in the minimally invasive group (6%). A multivariate analysis of this subgroup did not show higher odds of recurrence in the minimally invasive group.

Researchers observed no recurrences in 26 cases of minimally invasive surgery where no vaginal manipulator was used.

However, there were 19 recurrences (7%) in cases where an intra-uterine manipulator was used and 22 recurrences (11%) in cases where a vaginal manipulator was used.

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Researchers suggested further investigation of the manipulator’s role in increasing recurrence.

“The question is, where do we go from here? ... [We have to decide] if this is a fight worth fighting,” Uppal said. Whether [minimally invasive] hysterectomies should continue is up for debate. There are going to be some big questions about the cervical cancer centralization of care.” – by John DeRosier

Reference:

Uppal S, et al. Abstract 5504. Presented at: ASCO Annual Meeting; May 31-June 4, 2019; Chicago.

Disclosures: Uppal reports no relevant financial disclosures. Please see the abstract for all other authors’ relevant financial disclosures.

    Perspective
    Linus Chuang

    Linus Chuang

    This retrospective study by Uppal and colleagues comparing minimally invasive with open radical hysterectomy confirmed the finding of a study by Ramirez and colleagues published last year in The New England Journal of Medicine, but it’s still hard for many of us to accept because other studies that compared the minimally invasive approach with open surgery in other malignancies, such as uterine cancer and colon cancer, all showed equal outcomes with both procedures.

    Physicians are now understanding that this standard of care should be discussed with their patients before choosing a surgery approach.

    In medicine, one study rarely changes practice, but this seems to be coming out strong that we have to change our practice.

    There were a few issues with this research that primarily revolve around the lack of centralized pathology reviews, centralized imaging and consistent therapy afterward. Not having those is questionable, but this is still important research that has raised important questions.

    Going forward, researchers should look at the use of uterine manipulators, which could have an effect in disrupting and spreading the tumor. We need to ask if we can safely contain the tumor and remove it without using the manipulator.

    I don’t think we are at the end of the debate on minimally invasive vs. open radical hysterectomy yet. We should continue to search for an alternate way of performing minimally invasive radical hysterectomy for cervical cancer, because minimally invasive surgeries have a lower risk for comorbidities and increase the patient’s satisfaction and quality of life.

    Reference:

    Ramirez PT, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1806395.

    • Linus Chuang , MD
    • Western Connecticut Health Network

    Disclosures: Chuang reports no relevant financial disclosures

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