Abstract
Objective: Radical hysterectomy (RH) is the surgical standard for the treatment of the early-stage cervical cancer (CC). However, this procedure is associated with a high rate of adverse impact on the quality of the life of the patient. Since the rate of parametrial involvement (PI) is low for the patients with the early-stage CC, some authors believe that the patients with the early-stage CC may benefit from the less radical surgery. This study aims to estimate the incidence of the PI in the patients with the early-stage CC and establish a simple nomogram to identify a cohort of the patients with low risk of the PI who may benefit from the less radical surgery.Methods: All the patients who underwent the RH and pelvic lymphadenectomy were included from 2013 to 2018. The significant independent predictors were identified through the Cox regression analysis and then incorporated into a nomogram to predicate the PI. The calibration plots and receiver operating characteristic (ROC) curves were used to assess the predictive accuracy of the nomogram.Results: A total of 4,533 patients met the inclusion criteria and 441 women (9.7%) had the PI. The positive PI rate in the ≤2 cm group (1.2%) was significantly lower compared to >2– ≤4 cm (6.2%) or >4 cm (22.4%) groups. The multivariate analyses revealed that tumor size (p = 0.002), lymphovascular space invasion (LVSI) (p = 0.001), vaginal involvement (VI) (p < 0.001), status of the pelvic lymph nodes (PLNs) (p = 0.001), and depth of stromal invasion (DSI) (p < 0.001) were the independent prognostic factors of the PI. Finally, the five variables were combined to construct the nomogram model. The concordance indexes (C-indexes) of the PI were 0.756 (95% CI 0.726–0.786) for the internal validation and 0.729 (95% CI 0.678–0.780) for the external validation. The calibration plots further showed good consistency between the nomogram prediction and the actual observation.Conclusion: This study confirmed that the patients with tumor size 2 cm or smaller were at very low risk for the PI. If other variables such as negative LVSI, DSI <50%, no VI, and negative PLN were limited, the risk would reduce significantly. Meanwhile, a simple nomogram based on the significant clinicopathological characteristics could be used as a tool for the clinicians to predict the PI among the patients with the early-stage CC, who might benefit from a less radical surgery.
Highlights
Radical hysterectomy (RH) with pelvic lymphadenectomy has become the surgical standard for the treatment of the earlystage cervical cancer (CC) [1]
According to the Cox regression analysis, the parametrial involvement (PI) was strongly associated with tumor size (p = 0.002), the presence of lymphovascular space invasion (LVSI) (p < 0.001), vaginal involvement (p < 0.001), depth of stromal invasion (DSI) ≥ 50% (p < 0.001), and positive pelvic lymph nodes (PLNs) (p < 0.001) (Table 4)
Tumor size, LVSI, DSI, vaginal invasion (VI), and the status of PLN were all related to the occurrence of the PI (Figure 4)
Summary
Radical hysterectomy (RH) with pelvic lymphadenectomy has become the surgical standard for the treatment of the earlystage cervical cancer (CC) [1]. The procedure requires en bloc resection of the uterus and cervix along with the surrounding parametria to remove any micrometastatic lesions that have spread from the cervix [2]. Parametrectomy is the most difficult step of the RH and is generally considered as the main source of substantial complications. The occurrence of the complications can be attributed to the parametrial resection as part of the RH [3]. Some surgeons advocate a “nerve-sparing” technique that may minimize the occurrence of these complications, but the technique requires a specific learning curve and high surgical skills before being generalized [5, 6]
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