Completion of radical hysterectomy does not improve survival of patients with cervical cancer and intraoperatively detected lymph node involvement: ABRAX international retrospective cohort study

Abstract

Background: 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. Patients and methods: 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 IAeIIB, 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 Z 361) or abandoned (ABAND group, N Z 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. Results: The risks of recurrence (hazard ratio [HR] 1.154, 95% confidence intervals [CI] 0.799 e1.666, P Z 0.45), pelvic recurrence (HR 0.836, 95% CI 0.458e1.523, P Z 0.56), or death (HR 1.064, 95% CI 0.690e1.641, P Z 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. Conclusion: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. Clinical trials identifier: NCT04037124.

Report from the 36th Annual Meeting of the Korean Society of Gynecologic Oncology (KSGO)

“…Other opinions included the continuation of laparoscopic radical hysterectomy (29%), discontinuation of radical hysterectomy without paraaortic lymph node staging (24%) and conversion to open radical hysterectomy (9%). The ABRAX study was introduced by Dr. Jae Man Bae which demonstrated similar survival outcomes between those who completed radical hysterectomy and those who abandoned radical hysterectomy after finding pelvic lymph node metastasis intraoperatively [ 27 ].…”

Radiomic models for lymph node metastasis prediction in cervical cancer: can we think beyond sentinel lymph node?

“…In case the metastatic lymph node is detected intra-operatively (and possibly confirmed with a staging lymphadenectomy), both the literature evidence and the international guidelines recommend against the continuation of radical surgery in favor of definitive chemo-radiotherapy [ 5 , 6 ]. On the other hand, if the lymph node metastasis is diagnosed after radical hysterectomy and lymphadenectomy, adjuvant chemoradiation is indicated [ 3 , 5 ].…”

“…In early-stage cervical cancer, the prediction of the positive lymph node may allow avoiding any lymph nodal dissection, including SLN mapping, with the subsequent risk of performing radical surgery in lymph nodes positive patients [6] . Few studies have already shown that for selected very low-risk patients, the probability of metastasis in SLN is negligible and any kind of lymph node dissection could be avoided [15] , [16] : radiomics models may broaden the spectrum of patients in whom lymphadenectomy can be spared including also higher risk patients.…”

“…In locally advanced stages, it may spare lymphadenectomy-related morbidity and aid in deciding whether para-aortic extended-field radiotherapy is needed [ 6 , [17] , [18] , [19] ].…”

Rationale for the avoidance of parametrectomy and systematic lymphadenectomy in patients with early stages of neuroendocrine cervical cancer

“…The recently published ABRAX (ABandoning RAd hyst in cerviX cancer) study has not shown any survival benefit resulting from a completion of radical hysterectomy in patients with common cervical cancer types, in whom positive pelvic lymph nodes were diagnosed intraoperatively. 7 Taking into account the fact that neuroendocrine carcinoma is a very rare disease, it is not realistic to conduct prospective trials and come up with level I evidence on the significance of parametrectomy and systematic pelvic lymphadenectomy. Avoiding parametrectomy and limiting lymph node staging to sentinel lymph node biopsy…”