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Gynecologic Oncology Feb 2022After the LACC trial, the SUCCOR study, and other studies, we know that patients who have undergone minimally invasive surgery for cervical cancer have worse outcomes,... (Meta-Analysis)
Meta-Analysis
Pattern of relapse in patients with stage IB1 cervical cancer after radical hysterectomy as primary treatment. Minimally invasive surgery vs. open approach. Systematic review and meta-analysis.
BACKGROUND
After the LACC trial, the SUCCOR study, and other studies, we know that patients who have undergone minimally invasive surgery for cervical cancer have worse outcomes, but today, we do not know if the surgical approach can be a reason to change the pattern of relapses on these patients. We evaluated the relapse pattern in patients with stage IB1 cervical cancer (FIGO, 2009) who underwent radical hysterectomy with different surgical approaches.
METHODS
A systematic review of literature was performed in PubMed, Cochrane Library, Clinicaltrials.gov, and Web of science. Inclusion criteria were prospective or retrospective comparative studies of different surgical approaches that described patterns or locations of relapse in patients with stage IB1 cervical cancer. Heterogeneity was assessed by calculating I2.
RESULTS
The research resulted in 782 eligible citations from January 2010 to October 2020. After filtering, nine articles that met all inclusion criteria were analyzed, comprising data from 1663 patients who underwent radical hysterectomy for IB1 cervical cancer, and the incidence of relapse was 10.6%. When we compared the pattern of relapse (local, distant, and both) of each group (open surgery and minimally invasive surgery), we did not see statistically significant differences, (OR 0.963; 95% CI, 0.602-1.541; p = 0.898), (OR 0.788; 95% CI, 0.467-1.330; p = 0.542), and (OR 0.683; 95% CI, 0.331-1.407; p = 0.630), respectively.
CONCLUSION
There are no differences in patterns of relapse across surgical approaches in patients with stage IB1 cervical cancer undergoing radical hysterectomy as primary treatment.
Topics: Female; Humans; Hysterectomy; Laparoscopy; Laparotomy; Minimally Invasive Surgical Procedures; Neoplasm Recurrence, Local; Neoplasm Staging; Uterine Cervical Neoplasms
PubMed: 34848071
DOI: 10.1016/j.ygyno.2021.11.018 -
Deutsches Arzteblatt International Nov 2021Approximately 4380 cases of cervical carcinoma were diagnosed in Germany in 2016. In women who had not participated in early detection programs, cervical carcinoma was...
BACKGROUND
Approximately 4380 cases of cervical carcinoma were diagnosed in Germany in 2016. In women who had not participated in early detection programs, cervical carcinoma was usually already in an advanced stage at the time of diagnosis. Certified structures for care in conformity with the existing guidelines are available.
METHODS
The new German clinical practice guideline was revised with the participation of 50 medical societies under the expert guidance of the Guideline Program in Oncology, which includes the German Association of the Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). A systematic literature review was conducted. Systematic reviews, meta-analyses, and randomized controlled trials (RCTs) were considered.
RESULTS
The histologic tumor stage and lymph-node stage are essential determinants of the treatment strategy. The main innovation regarding surgical treatment is the revival of open hysterectomy (overall survival [minimally invasive vs open hysterectomy]: 94.04% vs 99.4%; hazard ratio [HR]: 6.00; 95% confidence interval [1.77; 20.30]). In addition, for tumors measuring 2 cm or less, sentinel node biopsy is recommended rather than radical pelvic lymphadenectomy. MRI-guided brachytherapy is an oblig atory component of radiochemotherapy (overall survival [radiochemotherapy with vs without brachytherapy]: 58.2% vs 46.2%, p<0.001). The standard palliative treatment consists of bevacizumab combined with a platinum-containing agent (overall survival: HR: 0.77 [0.62; 0.95]; p = 0.007).
CONCLUSION
Despite the introduction of new treatments, the outcome of patients with advanced cervical carcinoma has not much improved. In the surgical treatment of cervical carcinoma, the open approach is now favored. The sentinel node biopsy technique has become well established for the surgical staging of small tumors. Controlled trials are needed so that the outcome of women with cervical carcinoma, particularly in its advanced and metastatic stages, can be improved.
Topics: Aftercare; Carcinoma; Female; Humans; Hysterectomy; Lymph Node Excision; Neoplasm Staging; Uterine Cervical Neoplasms
PubMed: 34755595
DOI: 10.3238/arztebl.m2021.0352 -
Archives of Gynecology and Obstetrics Aug 2022Radical hysterectomy and pelvic lymphadenectomy is the standard treatment for early cervical cancer. Studies have shown superior oncological outcome for open versus... (Meta-Analysis)
Meta-Analysis Review
Perioperative morbidity of different operative approaches in early cervical carcinoma: a systematic review and meta-analysis comparing minimally invasive versus open radical hysterectomy.
PURPOSE
Radical hysterectomy and pelvic lymphadenectomy is the standard treatment for early cervical cancer. Studies have shown superior oncological outcome for open versus minimal invasive surgery, but peri- and postoperative complication rates were shown vice versa. This meta-analysis evaluates the peri- and postoperative morbidities and complications of robotic and laparoscopic radical hysterectomy compared to open surgery.
METHODS
Embase and Ovid-Medline databases were systematically searched in June 2020 for studies comparing robotic, laparoscopic and open radical hysterectomy. There was no limitation in publication year. Inclusion criteria were set analogue to the LACC trial. Subgroup analyses were performed regarding the operative technique, the study design and the date of publication for the endpoints intra- and postoperative morbidity, estimated blood loss, hospital stay and operation time.
RESULTS
27 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Meta-analysis showed no significant difference between robotic radical hysterectomy (RH) and laparoscopic hysterectomy (LH) concerning intra- and perioperative complications. Operation time was longer in both RH (mean difference 44.79 min [95% CI 38.16; 51.42]), and LH (mean difference 20.96 min; [95% CI - 1.30; 43.22]) than in open hysterectomy (AH) but did not lead to a rise of intra- and postoperative complications. Intraoperative morbidity was lower in LH than in AH (RR 0.90 [0.80; 1.02]) as well as in RH compared to AH (0.54 [0.33; 0.88]). Intraoperative morbidity showed no difference between LH and RH (RR 1.29 [0.23; 7.29]). Postoperative morbidity was not different in any approach. Estimated blood loss was lower in both LH (mean difference - 114.34 [- 122.97; - 105.71]) and RH (mean difference - 287.14 [- 392.99; - 181.28]) compared to AH, respectively. Duration of hospital stay was shorter for LH (mean difference - 3.06 [- 3.28; - 2.83]) and RH (mean difference - 3.77 [- 5.10; - 2.44]) compared to AH.
CONCLUSION
Minimally invasive radical hysterectomy appears to be associated with reduced intraoperative morbidity and blood loss and improved reconvalescence after surgery. Besides oncological and surgical factors these results should be considered when counseling patients for radical hysterectomy and underscore the need for new randomized trials.
Topics: Female; Humans; Hysterectomy; Laparoscopy; Morbidity; Postoperative Complications; Prospective Studies; Robotic Surgical Procedures; Uterine Cervical Neoplasms
PubMed: 34625835
DOI: 10.1007/s00404-021-06248-8 -
PloS One 2021This meta-analysis comprehensively compared intraoperative and postoperative complications between minimally invasive surgery (MIS) and laparotomy in the management of... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
This meta-analysis comprehensively compared intraoperative and postoperative complications between minimally invasive surgery (MIS) and laparotomy in the management of cervical cancer. Even though the advantages of laparotomy over MIS in disease-free survival and overall survival for management of gynecological diseases have been cited in the literature, there is a lack of substantial evidence of the advantage of one surgical modality over another, and it is uncertain whether MIS is justifiable in terms of safety and efficacy.
METHODS
In this meta-analysis, the studies were abstracted that the outcomes of complications to compare MIS (laparoscopic or robot-assisted) and open radical hysterectomy in patients with early-stage (International Federation of Gynecology and Obstetrics classification stage IA1-IIB) cervical cancer. The primary outcomes were intraoperative overall complications, as well as postoperative aggregate complications. Secondary outcomes included the individual complications. Two investigators independently performed the screening and data extraction. All articles that met the eligibility criteria were included in this meta-analysis.
RESULTS
The meta-analysis finally included 39 non-randomized studies and 1 randomized controlled trial (8 studies were conducted on robotic radical hysterectomy (RRH) vs open radical hysterectomy (ORH), 27 studies were conducted on laparoscopic radical hysterectomy (LRH) vs ORH, and 5 studies were conducted on all three approaches). Pooled analyses showed that MIS was associated with higher risk of intraoperative overall complications (OR = 1.41, 95% CI = 1.07-1.86, P<0.05) in comparison with ORH. However, compared to ORH, MIS was associated with significantly lower risk of postoperative aggregate complications (OR = 0.40, 95% CI = 0.34-0.48, P = 0.0143). In terms of individual complications, MIS appeared to have a positive effect in decreasing the complications of transfusion, wound infection, pelvic infection and abscess, lymphedema, intestinal obstruction, pulmonary embolism, deep vein thrombosis, and urinary tract infection. Furthermore, MIS had a negative effect in increasing the complications of cystotomy, bowel injury, subcutaneous emphysema, and fistula.
CONCLUSIONS
Our meta-analysis demonstrates that MIS is superior to laparotomy, with fewer postoperative overall complications (wound infection, pelvic infection and abscess, lymphedema, intestinal obstruction, pulmonary embolism, and urinary tract infection). However, MIS is associated with a higher risk of intraoperative aggregate complications (cystotomy, bowel injury, and subcutaneous emphysema) and postoperative fistula complications.
Topics: Disease-Free Survival; Female; Humans; Hysterectomy; Intraoperative Complications; Laparotomy; Minimally Invasive Surgical Procedures; Postoperative Complications; Robotic Surgical Procedures; Uterine Cervical Neoplasms
PubMed: 34197466
DOI: 10.1371/journal.pone.0253143 -
Archives of Gynecology and Obstetrics Aug 2021Villoglandular adenocarcinoma (VGA) of the uterine cervix has been classified as a rare subtype of cervical adenocarcinoma with good prognosis. A conservative surgical... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Villoglandular adenocarcinoma (VGA) of the uterine cervix has been classified as a rare subtype of cervical adenocarcinoma with good prognosis. A conservative surgical approach is considered feasible. The main risk factor is the presence of other histologic types of cancer. In this largest systematic review to date, we assess oncological outcomes associated with conservative therapy compared to those associated with invasive management in the treatment of stage Ia and Ib VGA.
METHODS
Case series and case reports identified by searching the PubMed database were eligible for inclusion in this review (stage Ia-Ib).
RESULTS
A total of 271 patients were included in our literature review. 54 (20%) patients were treated by "conservative management" (conization, simple hysterectomy, and trachelectomy) and 217 (80%) by "invasive management" (radical hysterectomy ± radiation, hysterectomy, and radiation). Recurrences of disease (RODs) were found in the conservative group in two (4%) cases and in the invasive group in nine (4%) cases. There was no significant difference in disease-free survival (DFS) according to conservative or invasive treatment (p = 0.75). The histology of VGA may be complex with underlying usual adenocarcinoma (UAC) combined with VGA.
CONCLUSION
The excellent prognosis of pure VGA and the young age of the patients may justify the management of this tumor using a less radical procedure. The histological diagnosis of VGA is a challenge, and pretreatment should not be based solely on a simple punch biopsy but rather a conization with wide tumor-free margins.
Topics: Adenocarcinoma; Conservative Treatment; Female; Humans; Hysterectomy; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Pregnancy; Uterine Cervical Neoplasms
PubMed: 34036437
DOI: 10.1007/s00404-021-06077-9 -
Archives of Gynecology and Obstetrics Sep 2021Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome... (Meta-Analysis)
Meta-Analysis Review
Protective operative techniques in radical hysterectomy in early cervical carcinoma and their influence on disease-free and overall survival: a systematic review and meta-analysis of risk groups.
PURPOSE
Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome for open versus minimal invasive surgery, however, the reasons remain to be speculated. This meta-analysis evaluates the outcomes of robotic and laparoscopic hysterectomy compared to open hysterectomy. Risk groups including the use of uterine manipulators or colpotomy were created.
METHODS
Ovid-Medline and Embase databases were systematically searched in June 2020. No limitation in date of publication or country was made. Subgroup analyses were performed regarding the surgical approach and the endpoints OS and DFS.
RESULTS
30 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Patients were analyzed concerning the surgical approach [open surgery (AH), laparoscopic surgery (LH), robotic surgery (RH)]. Additionally, three subgroups were created from the LH group: the LH high-risk group (manipulator), intermediate-risk group (no manipulator, intracorporal colpotomy) and LH low-risk group (no manipulator, vaginal colpotomy). Regarding OS, the meta-analysis showed inferiority of LH in total over AH (0.97 [0.96; 0.98]). The OS was significantly higher in LH low risk (0.96 [0.94; 0.98) compared to LH intermediate risk (0.93 [0.91; 0.94]). OS rates were comparable in AH and LH Low-risk group. DFS was higher in the AH group compared to the LH group in general (0.92 [95%-CI 0.88; 0.95] vs. 0.87 [0.82; 0.91]), whereas the application of protective measures (no uterine manipulator in combination with vaginal colpotomy) was associated with increased DFS in laparoscopy (0.91 [0.91; 0.95]).
CONCLUSION
DFS and OS in laparoscopy appear to be depending on surgical technique. Protective operating techniques in laparoscopy result in improved minimal invasive survival.
Topics: Carcinoma, Squamous Cell; Colpotomy; Early Detection of Cancer; Female; Humans; Hysterectomy; Laparoscopy; Minimally Invasive Surgical Procedures; Pregnancy; Uterine Cervical Neoplasms
PubMed: 34021804
DOI: 10.1007/s00404-021-06082-y -
International Journal of Gynecological... Jul 2021To investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor size 2 cm who underwent open or minimally invasive radical hysterectomy. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor size 2 cm who underwent open or minimally invasive radical hysterectomy.
METHODS
The Pubmed/Medline, Embase, and Web-of-Science databases were queried from inception to January 2021 (PROSPERO CRD 42020207971). Observational studies reporting progression-free survival and/or overall survival for patients who had open or minimally invasive radical hysterectomy for early-stage cervical carcinoma and tumor size 2 cm were selected. Level of statistical heterogeneity was evaluated with the I statistic. A random-effects model was used to compare progression and overall survival between the two groups and HR with 95% confidence intervals were calculated with the Der Simonian and Laird approach. Risk of bias and quality of included studies was assessed with the Newcastle-Ottawa scale.
RESULTS
A total of 10 studies that met the inclusion criteria were included encompassing 4935 patients. Of these, 2394 (48.5%) patients had minimally invasive and 2541 (51.5%) patients had open radical hysterectomy; respectively. Patients who underwent minimally invasive hysterectomy had worse progression-free survival than those who had open surgery (HR 1.68, 95% CI 1.20, 2.36, I 26%). Based on five studies, patients who had minimally invasive (n=1808) hysterectomy had a trend towards worse overall survival than those who had open surgery (n=1853) (HR 1.64, 95% CI 1.00 to 2.68, I 15%).
CONCLUSION
Based on a systematic review of the literature and meta-analysis of studies that control for confounders, for patients with cervical cancer and tumor size 2 cm, minimally invasive radical hysterectomy was associated with worse progression-free survival than laparotomy.
Topics: Female; Humans; Hysterectomy; Minimally Invasive Surgical Procedures; Neoplasm Staging; Progression-Free Survival; Treatment Outcome; Uterine Cervical Neoplasms
PubMed: 34016701
DOI: 10.1136/ijgc-2021-002505 -
Oncology Research and Treatment 2021To compare the efficacy and safety of radical surgery with radiotherapy in patients with early-stage cervical carcinoma. (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
To compare the efficacy and safety of radical surgery with radiotherapy in patients with early-stage cervical carcinoma.
METHODS
PubMed, Web of Science, and Embase were systematically reviewed, and studies comparing radical surgery with radiotherapy were included. The main efficacy outcomes included overall survival (OS), and disease-free survival (DFS). Safety endpoints were adverse events. Hazard ratios (HR) or risk ratios (RR) with 95% CI were used to pool the estimates.
RESULTS
A total of 6 studies were included in this meta-analysis. Radical surgery was associated with comparable survival effects in OS (HR = 0.73; 95% CI 0.46-1.17; p = 0.196) and DFS (HR = 0.84; 95% CI 0.64-1.10; p = 0.207) as compared with radiotherapy. Moreover, positive lymphangiography (HR = 3.67; 95% CI 2.86-4.70; p < 0.001), adeno-carcinomatous histotype (HR = 2.53; 95% CI 1.80-3.56; p < 0.001), adenosquamous histotype (HR = 1.55; 95% CI 1.27-1.89; p < 0.001), tumor size ≥4 cm (HR = 1.60; 95% CI 1.14-2.23; p < 0.001), stage IB2 (HR = 1.71; 95% CI 1.43-2.04; p < 0.001), and stage IIA (HR = 1.85; 95% CI 1.54-2.22; p < 0.001) were all independent predictors of decreased survival. Patients treated with radical surgery had a rate of adverse events similar to that of those treated with radiotherapy (RR = 1.23; 95% CI 0.61-2.48; p = 0.557).
CONCLUSION
The present study suggested that radical surgery and radiotherapy offered similarly effective treatment in terms of OS and DFS in early-stage cervical carcinoma. Moreover, the complication rate between the 2 treatments was not significantly different. Considering the potential limitations of this study, more large-scale well-designed randomized controlled trials are needed to verify our findings.
Topics: Disease-Free Survival; Female; Humans; Hysterectomy; Neoplasm Staging; Progression-Free Survival; Randomized Controlled Trials as Topic; Uterine Cervical Neoplasms
PubMed: 33706315
DOI: 10.1159/000509149 -
International Journal of Gynecological... Mar 2021Management of cervical cancer tumors >2 cm has been a subject of controversy, with management often considered as either up-front radical trachelectomy or neoadjuvant...
BACKGROUND
Management of cervical cancer tumors >2 cm has been a subject of controversy, with management often considered as either up-front radical trachelectomy or neoadjuvant chemotherapy before fertility-sparing surgery.
METHODS
A systematic literature review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) checklist. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO). We searched Medline through PubMed, EMBASE, Cochrane Central Register of Controlled Trials, SCOPUS, and OVID between January 1985 and December 2020. Eligibility criteria for selecting studies were English language, randomized controlled trials, and observational studies including information on fertility and oncologic outcomes. All titles were managed in EndNote X7. Risk of bias was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist for observational studies.
RESULTS
Twenty-three studies with 205 patients who received neoadjuvant chemotherapy were included. The majority of patients (92.2%, n=189) had stage IB FIGO 2009 cervical cancer. The preferred regimen used was cisplatin in combination with paclitaxel or ifosfamide (80%, n=164). One hundred and eighty patients (87.8%) underwent fertility-sparing surgery; radical vaginal trachelectomy, abdominal trachelectomy, conization, and simple trachelectomy were performed in 62 (34.4%), 49 (27.2%), 34 (18.9%), and 26 (14.4%) women, respectively. In nine patients (5%) the type of procedure was not specified. The follow-up time reported in all studies ranged between 6 and 69 months. In 112 women who sought a pregnancy after surgery, 84.8% (n=95) achieved a gestation.The global recurrence and death rates were 12.8% and 2.8%, respectively.
CONCLUSION
Neoadjuvant chemotherapy followed by fertility-sparing surgery is a promising strategy that might allow fertility preservation in highly selected patients with cervical cancer with tumors >2 cm while providing acceptable oncologic outcomes. Results of prospective studies are required to validate its oncological safety.
SYSTEMATIC REVIEW REGISTRATION NUMBER
PROSPERO CRD42020203789.
Topics: Antineoplastic Combined Chemotherapy Protocols; Female; Fertility Preservation; Humans; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Patient Selection; Pregnancy; Trachelectomy; Uterine Cervical Neoplasms
PubMed: 33649006
DOI: 10.1136/ijgc-2020-001765 -
Oncology Letters Feb 2021The benefit of adjuvant hysterectomy after definitive concurrent chemoradiotherapy (CCRT) for locally-advanced cervical cancer (LACC) is controversial. The purpose of...
The benefit of adjuvant hysterectomy after definitive concurrent chemoradiotherapy (CCRT) for locally-advanced cervical cancer (LACC) is controversial. The purpose of the present study was to systematically search the literature and perform a meta-analysis to compare overall survival (OS) and disease-free survival (DFS) between patients subjected to CCRT with hysterectomy and those who underwent CCRT alone. The PubMed, Scopus, Embase and Google scholar databases were searched. A meta-analysis to determine hazard ratios (HRs) and odds ratios (ORs) with meta-regression was performed for the following moderators: Disease stage, histology and proportion of radical hysterectomy. Data from 14 studies were included. The results indicated that patients who received CCRT with hysterectomy had significantly better OS (HR, 0.72; 95% CI, 0.56 to 0.91; I=19%; P=0.007) and DFS (HR, 0.72; 95% CI, 0.56 to 0.93; I=27%; P=0.01) than those treated with CCRT alone. However, in a subgroup analysis by study type, the results were significant only for retrospective studies but not for randomized controlled trials (RCTs). However, only 2 RCTs were included with small sample size, heterogeneity and low overall quality. Subgroup analyses based on the use of brachytherapy in the CCRT with hysterectomy group demonstrated no difference in OS and DFS between the two groups. Regarding the absolute numbers of death and recurrence events, no significant difference in mortality (OR, 0.91; 95% CI, 0.62 to 1.33; I=0%; P=0.64) was determined between the two groups, but a significantly reduced incidence of recurrence was observed in the CCRT with hysterectomy group (OR, 0.61; 95% CI, 0.47-0.79; I=29%; P=0.0002). The meta-regression results point to a significant influence of the proportion of stage II patients on OS. Despite the overall analysis indicating improved OS and DFS with the use of adjuvant hysterectomy after CCRT, subgroup analysis based on similar treatment protocols failed to demonstrate any significant benefit of hysterectomy in LACC. However, the results indicated that the recurrence rate may be higher in patients undergoing CCRT without hysterectomy. The limited quality of the studies included and selection bias from retrospective studies restrict the possibility to draw strong conclusions.
PubMed: 33552278
DOI: 10.3892/ol.2020.12421