Challenges and Controversies in the Surgical Treatment of Cervical Cancer: Open Radical Hysterectomy versus Minimally Invasive Radical Hysterectomy.

Jona Röseler,Marie Debrouwere,Friedemann Geiger,Helder Ferreira,Fülöp Scheibler,Robert Wolff,Peter Hillemanns,Mohamed Elessawy,Nicolai Maass,Dirk O Bauerschlag

doi:10.3390/jcm10173761

Abstract

Objective: The aim of the study was to perform a systematic assessment of disease-free survival (DFS), overall survival, and morbidity rates after open radical hysterectomy (ORH) and minimally invasive surgery (MIS) for early-stage cervical cancer and discuss with experts the consequences of the LACC trial (published by Ramirez et al. in 2018) on clinical routine. Methods: A total of 5428 records were retrieved. After exclusion based on text screening, four records were identified for inclusion. Five experts from three independent large-volume medical centers in Europe were interviewed for their interpretation of the LACC trial. Results: The LACC trial showed a significantly higher risk of disease progression with MIS compared to ORH (HR 3.74, 95% CI 1.63 to 8.58). This was not seen in one epidemiological study and was contradicted by one prospective cohort study reported by Greggi et al. A systematic review by Zhang et al. mentioned a similar DFS for robot-assisted radical hysterectomy (RRH) and LRH. Recurrence rates were significantly higher with MIS compared to ORH in the LACC trial (HR 4.26, 95% CI 1.44 to 12.60). In contrast, four studies presented by Greggi reported no significant difference in recurrence rates between LRH/RRH and ORH, which concurred with the systematic reviews of Zhang and Zhao. The experts mentioned various limitations of the LACC trial and stated that clinicians were obliged to provide patients with detailed information and ensure a shared decision-making process. Conclusions: The surgical treatment of early-stage cervical cancer remains a debated issue. More randomized controlled trials (RCT) will be needed to establish the most suitable treatment for this condition.

Highlights

In 2018, Ramirez et al published the results of a randomized controlled trial (RCT) on the laparoscopic approach to cervical cancer (LACC) in the New England Journal of Medicine [1]
The authors concluded that minimally invasive radical hysterectomy was associated with lower rates of overall survival and disease-free survival compared to open radical hysterectomy (ORH) [1]
Despite some issues regarding the implementation of the LACC trial, the ESMO issued an amendment of their guidelines, by which radical hysterectomy performed by laparoscopy or robot-assisted surgery may no longer be given preference over open surgery for patients with FIGO stage 2019 IA2, IB, and IIA [6,7]

Summary

Introduction

In 2018, Ramirez et al published the results of a randomized controlled trial (RCT) on the laparoscopic approach to cervical cancer (LACC) in the New England Journal of Medicine [1] This non-inferiority trial evaluated survival rates after minimally invasive surgery (MIS) versus open radical hysterectomy (ORH) for early-stage cervical cancer (FIGO stage 2009 IA1 with lymphovascular invasion, IA2, or IB1). The authors concluded that minimally invasive radical hysterectomy was associated with lower rates of overall survival and disease-free survival compared to ORH [1]. These data had a striking impact on gynecological surgery throughout the world. Despite some issues regarding the implementation of the LACC trial, the ESMO issued an amendment of their guidelines, by which radical hysterectomy performed by laparoscopy or robot-assisted surgery may no longer be given preference over open surgery for patients with FIGO stage 2019 IA2, IB, and IIA [6,7]

Methods

Results

Conclusion