The Role of Conization before Radical Hysterectomy in Cervical Cancer including High Risk Factors of Recurrence: Propensity Score Matching

Abstract

We primarily aimed to investigate the therapeutic role of conization prior to radical hysterectomy for cervical cancer. Secondarily, we aimed to characterize a subgroup of patients who could potentially benefit from preoperative conization. Patients who underwent radical hysterectomy for FIGO 2009 stage IB1 to IIB cervical cancer from 1995 to 2020 were eligible. The patients were divided into two groups: those with and without preoperative conization. To adjust for the baseline characteristics of the two groups, 1:2 case–control propensity score matching was conducted. Survival analysis was performed between the two groups. Subgroup analysis was performed to identify the effect of conization based on clinical and pathological factors. Patients who underwent preoperative conization showed better 5-year overall survival than those who did not (95.9% vs. 93.0%, p = 0.029); however, no difference was observed in progression-free survival (88.9% vs. 85.9%, p = 0.155). In multivariate Cox analysis, conization showed a 55% reduction in recurrence (hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.41–1.01, p = 0.056) and 41% reduction in death (HR 0.59, 95% CI 0.34–1.02, p = 0.059), but with marginal statistical significance. In subgroup analysis, minimally invasive surgery (MIS), negative pelvic lymph node, and tumor size < 4 cm showed improved survival from conization. Conization before radical hysterectomy may be associated with improved survival in patients with early-stage cervical cancer. This information could serve as a basis for a more tailored patient selection for MIS for cervical cancer.

Outcomes of Radical Hysterectomy for Early-Stage Cervical Carcinoma, with or without Prior Cervical Excision Procedure

“…Although patients who had preoperative conization had smaller tumors, when examining patients with FIGO 2009 stage IB1 disease, preoperative conization was again associated with a lower risk of tumor relapse (1.8% vs. 17.2%, p = 0.004) [ 9 ]. Similarly, in another study following propensity score matching among patients who had minimally invasive radical hysterectomy (n = 397), the performance of preoperative conization (n = 256) was associated with better progression-free (5-year rates: 91.2% vs. 82.7%, p = 0.021) and overall (5-year rates: 96.9% vs. 93.2%, p = 0.066) survival [ 26 ]. In another retrospective study with a long follow-up, which included patients with stage IB disease and a tumor size ≤2 cm, those who underwent minimally invasive surgery without prior conization (n = 62) had increased risk of relapse compared to those who underwent prior conization (n = 94) [ 27 ].…”

Controversies and Advances in the Personalized Surgical Treatment of Cervical Cancer

“…The importance of the finding was underlined by a significant decrease in relapse rates (65% reduction). In another retrospective study that was conducted in Korea and which involved 1799 patients of whom 291 underwent preoperative conization, researchers denoted that this finding may be true, as the multivariate analysis showed that conization was associated with a 55% reduction in recurrence rates (HR 0.65, 95% CI 0.34–1.02) and a 41% reduction in death rates (HR 0.59, 95% CI 0.34–1.02), both of them achieving a marginal statistical significance [ 37 ]. It should be noted that the large sample size permitted the use of propensity score matching, hence limiting the possibility of bias that arises from several confounding factors, including stage, grade of differentiation, patient age, type of procedure (radicality and use of minimally invasive techniques), presence of lymphovascular space involvement and parametrial involvement and positive resection margins.…”

Laparoscopic radical hysterectomy without uterine manipulator or vaginal tube use

“…This technique was targeted at patients with stage IB1, IB2, and IIA1 uterine cervical neoplasm according to the revised 2018 FIGO staging system, and patients with tumors sized <4 cm. Although cervical conization is not a necessary technique to perform this surgical procedure, many retrospective studies have recently come out that preop cervical conization is helpful in efforts to lower the risk of MIS, and this research team has recently performed conization before surgery [ 9 10 ].…”