Early invasive cervical cancer with pelvic lymph node involvement: To complete or not to complete radical hysterectomy?

doi:10.1016/0090-8258(90)90312-9

Gynecologic Oncology

Volume 37, Issue 1, April 1990, Pages 78-81

https://doi.org/10.1016/0090-8258(90)90312-9 Get rights and content

Abstract

The completion of radical hysterectomy in the face of pelvic lymph node involvement presents a dilemma for the surgeon. Some believe it is appropriate to abort the hysterectomy to avoid the excessive morbidity of combined treatment; others believe that completion of the hysterectomy enhances survival. This study was undertaken to define the impact of completing radical hysterectomy followed by adjuvant radiation therapy upon patient survival or pelvic control. Fifteen patients with stage IB and IIA invasive cervical cancer whose radical hysterectomies were aborted solely for reasons of pelvic lymph node involvement were compared to a control group of 15 patients matched for tumor size and number of lymph nodes involved whose radical hysterectomies were completed. Both groups were treated with radiation therapy postoperatively. Survival was not different between groups (P = 0.81). Unexpectedly, local control was slightly improved in the group treated by radiation only (P = 0.127). If radiation therapy is anticipated, completion of radical hysterectomy followed by radiation therapy appears to offer no advantage over radiation therapy with the uterus in place in patients with early-stage invasive cervical cancer and pelvic lymph node involvement.

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Cited by (51)

Completion of radical hysterectomy does not improve survival of patients with cervical cancer and intraoperatively detected lymph node involvement: ABRAX international retrospective cohort study
2021, European Journal of Cancer
Citation Excerpt :
However, there are limited and inconsistent data for patients in whom radical hysterectomy was abandoned due to intraoperatively detected lymph node involvement. Prior studies included small, heterogeneous groups of patients, mostly with gross lymph node involvement that was not detected pre-operatively due to the absence of modern imaging in the work-up [10–16]. Therefore, we established collaboration with international gynaecological centres that saw a high volume of cervical cancer to obtain retrospective data on a large cohort of patients with intraoperatively detected lymph node involvement who underwent either radical uterine procedure followed by adjuvant (chemo)radiotherapy or definitive chemoradiotherapy without a prior radical uterine procedure.
The management of cervical cancer patients with intraoperative detection of lymph node involvement remains controversial. 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 ABRAX study investigated whether completing a radical uterine procedure is associated with an improved oncological outcome of such patients.
We performed retrospective analyses of 515 cervical cancer patients (51 institutions, 19 countries) who were referred for primary curative surgery between 2005 and 2015 (stage IA–IIB, common tumour types) in whom lymph node involvement was detected intraoperatively. Patients were stratified according to whether the planned uterine surgery was completed (COMPL group, N = 361) or abandoned (ABAND group, N = 154) to compare progression-free survival. Definitive chemoradiation was given to 92.9% patients in the ABAND group and adjuvant (chemo)radiation or chemotherapy to 91.4% of patients in the COMPL group.
The risks of recurrence (hazard ratio [HR] 1.154, 95% confidence intervals [CI] 0.799–1.666, P = 0.45), pelvic recurrence (HR 0.836, 95% CI 0.458–1.523, P = 0.56), or death (HR 1.064, 95% CI 0.690–1.641, P = 0.78) were not significantly different between the two groups. No subgroup showed a survival benefit from completing radical hysterectomy. Disease-free survival reached 74% (381/515), with a median follow-up of 58 months. Prognostic factors were balanced between the two groups. FIGO stage and number of pelvic lymph nodes involved were significant prognostic factors in the whole study cohort.
We showed that the completion of radical hysterectomy does not improve survival in patients with intraoperatively detected lymph node involvement, regardless of tumour size or histological type. If lymph node involvement is confirmed intraoperatively, abandoning uterine radical procedure should be considered, and the patient should be referred for definitive chemoradiation.
NCT04037124.
Abdominal Radical Hysterectomy
2018, Principles of Gynecologic Oncology Surgery
Radical hysterectomy remains the standard recommendation for patients with early-stage (stage IA2–IIA) cervical cancer. Patient selection is critical to decrease the risk of adjuvant therapy. Excellent knowledge of anatomic landmarks is paramount when this complex pelvic procedure is performed. The extent of the procedure is based on the extent of radicality, as determined by the Morrow and Querleu classification, and it should be tailored according to disease characteristics. This chapter aims to describe key elements in patient selection, evaluation, and surgical approaches. The steps of the procedure are outlined with a major emphasis on crucial anatomic landmarks. In addition, details on the perioperative complications, along with diagnosis and management of such complications, are discussed.
IKKβ/NF-κB mediated the low doses of bisphenol A induced migration of cervical cancer cells
2015, Archives of Biochemistry and Biophysics
Cervical cancer is considered as the second most common female malignant disease. There is an urgent need to illustrate risk factors which can trigger the motility of cervical cancer cells. Our present study revealed that nanomolar concentration of bisphenol A (BPA) significantly promoted the in vitro migration and invasion of cervical cancer HeLa, SiHa, and C-33A cells. Further, BPA treatment increased the expression of metalloproteinase-9 (MMP-9) and fibronectin (FN) in both HeLa and SiHa cells, while did not obviously change the expression of MMP-2, vimentin (Vim) or N-Cadherin (N-Cad). BAY 11-7082, the inhibitor of NF-κB, significantly abolished BPA induced up regulation of FN and MMP-9 in cervical cancer cells. While the inhibitors of PKA (H89), ERK1/2 (PD 98059), EGFR (AG1478), or PI3K/Akt (LY294002) had no effect on the expression of either FN or MMP-9. BPA treatment rapidly increased the phosphorylation of both IκBα and p65, stimulated nuclear translocation, and up regulated the promoter activities of NF-κB. The BPA induced up regulation of MMP-9 and FN and activation of NF-κB were mediated by phosphorylation of IKKβ via PKC signals. Collectively, our study found for the first time that BPA stimulated the cervical cancer migration via IKK-β/NF-κB signals.
Completed versus aborted radical hysterectomy for node-positive stage IB cervical cancer in the modern era of chemoradiation therapy
2012, Gynecologic Oncology
Citation Excerpt :
The authors concluded administration of adjuvant radiation following radical surgery is associated with significant morbidity. This concern has been noted in other studies as well [4,11] and is still a key concern noted among members of the SGO [10]. In our study, while no statistically significant difference was noted between cohorts due to the small study population, it is interesting that there was a seeming improvement in PFS and OS in patients undergoing completion of radical hysterectomy.
Debate continues about optimal management of patients with node-positive stage I cervical cancer. Our objective was to determine if patient outcomes are affected by radical hysterectomy in the modern era of adjuvant chemoradiation.
Cervical cancer patients diagnosed from 2000 to 2008 were identified. Demographics, therapy, clinicopathologic data, progression free survival (PFS), overall survival (OS), total radiation exposure, and grade 3–4 complications were analyzed by student t, Mann–Whitney, Fisher's exact, Kaplan–Meier, and log rank tests.
This single-institution review evaluated forty-one of 334 (13.4%) patients scheduled to undergo radical hysterectomy that had gross nodal disease diagnosed intraoperatively. 15 underwent aborted radical hysterectomy following lymphadenectomy; the remaining 26 underwent radical hysterectomy and lymphadenectomy. Eleven patients undergoing radical hysterectomy underwent whole pelvic radiation therapy (WPRT) while 8 (30.7%) patients underwent WPRT and postoperative vaginal brachytherapy (BT) for local treatment secondary to close margins. All patients undergoing aborted radical hysterectomy underwent WPRT and BT. With mean follow-up of 42.3 months, there were no significant differences in urinary, gastrointestinal, or hematologic complications between groups. When comparing those undergoing radical hysterectomy to aborted radical hysterectomy, there were no significant differences in local recurrence (11.5% vs 26.7%, p = 0.39) or distant recurrence (19.2% vs. 33.3%, p = 0.45), PFS (74.9 months vs 46.8 months, p = 0.106), or OS (91.8 months vs 69.4 months, p = 0.886).
Treatment of patients with early stage cervical cancer and nodal metastasis may be tailored intraoperatively. Completion of radical hysterectomy and lymphadenectomy decreases radiation exposure without apparently compromising safety or outcome in the era of adjuvant chemoradiation.
MiR-375 is down-regulated in squamous cervical cancer and inhibits cell migration and invasion via targeting transcription factor SP1
2011, American Journal of Pathology
Pelvic lymph node metastases are regarded as the most important risk factor and a predictor of poor prognosis for patients with cervical cancer. Exploration of metastasis-related molecules is helpful toward improving the prognosis in cervical cancer. To identify the role of miR-375 in metastasis and progression of cervical cancer, we examined the expression of miR-375 in 170 cervical cancer tissues and 68 normal cervical tissues, using stem-loop quantitative PCR, and found that the expression of miR-375 in cervical cancer tissues was significantly decreased by 4.45-fold, compared with 68 normal tissues. A significant correlation existed between miR-375 expression and clinicopathologic parameters, including lymph node metastasis of cervical cancer. Overexpressed miR-375 suppressed cell proliferation, blocked G1-to-S cell-cycle transition, and inhibited cell migration and invasion in human cervical SiHa and CaSki cells. SP1, a potential target gene of miR-375, was inversely correlated with miR-375 expression in cervical cancer tissues. Moreover, SP1 was negatively regulated by miR-375, and knockdown of SP1 by siRNA inhibited cell malignant behaviors. Thus, our findings suggest that down-regulated miR-375 promotes cell malignant behaviors via the target gene SP1 and may consequently contribute to the progression of cervical cancer.
Intra-operative detection of nodal metastasis in early stage cervical cancer: A survey of the practice patterns of SGO members
2011, Gynecologic Oncology
Citation Excerpt :
A large number of respondents stated that performance of RH before the administration of RT optimizes pelvic control. Of the 4 studies comparing outcomes between aborted and completed RH groups in early stage cervical cancer; pelvic control was not evaluated in one [6], better in the completed RH group in another [9], and not significantly different between groups in the remaining two studies [4,7]. Because patients who underwent aborted RH as compared to those who underwent completed RH for early stage cervical cancer were not uniform prognostically, it is unclear whether pelvic recurrence rates differ between these two groups.
To determine the practice patterns of members of Society of Gynecologic Oncologists (SGO) in different clinical situations involving the intra-operative detection of nodal metastasis in early stage cervical cancer.
A study questionnaire was mailed to the current members of SGO (n = 874). Data were collected using an internet survey database. Frequency distributions were determined, and non parametric tests were performed.
Thirty percent SGO members responded (n = 274). Only 38.6% routinely performed an intra-operative frozen section evaluation of the lymph nodes. Of these; most (79%) did not abort the radical hysterectomy (RH) for an isolated microscopically positive pelvic lymph node. The likelihood of aborting RH for microscopic nodal involvement increased however with number of positive pelvic lymph nodes (21% with 1, 40% with 2–3, and 61% with > 3 positive pelvic lymph nodes), involvement of para-aortic lymph nodes (61%), or bilaterally positive lymph nodes (54%). Similarly, a large number did not complete the RH due to gross involvement of pelvic (45%) or para-aortic lymph node/s (69%). Most (90%) completed the lymphadenectomy before aborting RH. When completing RH, the majority tailored its extent to perform a less radical resection. Variables significantly associated with the likelihood of completing RH in different clinical situations included: location of current practice (West), practice type (private), years in practice (> 15 years), and number of cases seen per year (> 10/month).
Practice patterns of SGO members are considerably diverse, which is reflective of the conflicting evidence available in the literature. Well designed studies are required to determine the best overall approach.

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Early invasive cervical cancer with pelvic lymph node involvement: To complete or not to complete radical hysterectomy?

Abstract

Amer. J. Obstet. Gynecol.

Amer. J. Obstet. Gynecol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.