No survival benefit found after radical hysterectomy when cervical cancer is discovered in lymph nodes intraoperatively

Since radical hysterectomy does not improve survival, the procedure should be replaced with definitive chemoradiation, according to the ABRAX study published in the European Journal of Cancer.

Definitive chemoradiation should be used in place of radical hysterectomy for cervical cancer patients with intraoperatively discovered lymph node involvement, according to a retrospective analysis.

The study was conducted by David Cibula, MD, PHD, who is a professor in the Department of Obstetrics and Gynaecology at First Faculty of Medicine at the Charles University and General University Hospital in Prague and collaborating authors.

Researchers noted that the management of cervical cancer patients with intraoperatively discovered lymph node involvement is contentious. “Since all these patients are referred for (chemo)radiation after the surgery, the key decision is whether radical hysterectomy should be completed as originally planned, taking into account an additional morbidity associated with extensive surgical dissection prior to adjuvant treatment,” the authors said.

The analysis examined 515 cervical cancer patients in 19 countries who were treated in 51 institutions between 2005 and 2015. Patients had been referred for primary curative surgery for stage IA-IIB, common tumor types where lymph node involvement was found intraoperatively. Patients were placed into a completed surgical group (361) and an abandoned surgical group (154) and had progression-free survival compared. In the abandoned group, 92.9% of patients were treated with definitive chemoradiation. Adjuvant (chemo)radiation or chemotherapy was given to 91.4% of patients in the completed surgical group.

Study authors reported no significant difference in recurrence risk, pelvic recurrence, or death. They also said no subgroup had a survival benefit from radical hysterectomy. They reported disease-free survival in 381 patients, a rate of 74%, after a median follow up of 58 months. They said prognostic factors between the two groups were balanced.

“FIGO stage and number of pelvic lymph nodes involved were significant prognostic factors in the whole study cohort,” the authors said.

In an interview with Contemporary OB/GYN, Cibula said the most significant aspect of the research is the international collaboration that made it possible for the study to represent the largest cohort by far of cervical cancer patients in whom lymph node involvement was detected intraoperatively. He said that the authors “tried to avoid the limitations of some previous smaller studies, excluding patients with positive lymph nodes from pre-operative work-up or from final pathology.”

For next steps, Cibula told Contemporary OB/GYN that although this was a retrospective study, “it is very unlikely that a prospective study can ever be performed since it would require the screening of more than 7,000 patients with early-stage cervical cancer. It is very unlikely that a significant benefit could be found since our study in well-balanced groups comparing the two different approaches did not reveal even a signal towards better survival or local disease control in any patients´ subgroup.”

Cibula emphasized the analyses’ results in his interview, so that physicians in practice can confidently abandon radical hysterectomy in favor of definitive chemoradiation. “We did not find a survival benefit from the completion of radical hysterectomy in any subgroup of patients, irrespective of histological type, disease stage, or tumor size,” he said.

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Reference

  1. Cibula D, Dostalek L, Hillemanns P, et al. Completion of radical hysterectomy does not improve survival of patients with cervical cancer and intraoperatively detected lymph node involvement: ABRAX international retrospective cohort study. [published online ahead of print, 2020 Dec 5]. Eur J Cancer. 2020;143:88-100. doi:10.1016/j.ejca.2020.10.037.