Minimally-Invasive Radical Hysterectomy for Cancer of the Cervix: The Perspective of the Society of Gynecologic Oncology of Canada (GOC)

摘要

A randomized controlled trial1Ramirez PT Frumovitz M Pareja R et al.Minimally invasive versus abdominal radical hysterectomy for cervical cancer.N Engl J Med. 2018; 379: 1895-1904Crossref PubMed Scopus (937) Google Scholar and a two-part cancer registry study,2Melamed A Margul DJ Chen L et al.Survival after minimally invasive radical hysterectomy for early-stage cervical cancer.N Engl J Med. 2018; 379: 1905-1914Crossref PubMed Scopus (407) Google Scholar published in the New England Journal of Medicine, report increased recurrence and mortality rates with the use of minimally invasive (MIS) radical hysterectomy as compared to laparotomy for women with cancer of the cervix. These results have important implications that could lead to changes in practice in the surgical treatment of cancer of the cervix. Based on the findings in these two studies, careful scientific investigation is necessary to evaluate which biological, technical, or surgical factors may explain the observed deleterious effect of MIS in cervical cancer that have not been observed in randomized trials in other solid tumours, such as endometrial3Walker JL Piedimonte MR Spirtos NM et al.Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study.J Clin Oncol. 2012; 30: 695-700Crossref PubMed Scopus (502) Google Scholar gastric,4Kim YW Yoon HM Yun YH et al.Long-term outcomes of laparoscopy-assisted distal gastrectomy for early gastric cancer: result of a randomized controlled trial (COACT 0302).Surg Endosc. 2013; 27: 4267-4276Crossref PubMed Scopus (102) Google Scholar and colorectal cancer.5Bonjer HJ Deijen CL Abis GA A randomized trial of laparoscopic versus open surgery for rectal cancer.N Engl J Med. 2015; 372: 1324-1332Crossref PubMed Scopus (833) Google Scholar, 6Kitano S Inomata M Mizusawa J et al.Survival outcomes following laparoscopic versus open D3 dissection for stage II or III colon cancer (JCOG0404): a phase 3, randomised controlled trial.Lancet Gastroenterol Hepatol. 2017; 2: 261-268Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 7Jeong SY Park JW Nam BH et al.Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial.Lancet Oncol. 2014; 15: 767-774Abstract Full Text Full Text PDF PubMed Scopus (588) Google Scholar Once the factors driving worse outcomes are better understood, practice guidelines can be updated to enhance the care of patients with cancer of the cervix in Canada. The Laparoscopic Approach to Cervical Cancer trial (LACC) is a randomized international multicentre study including 631 patients with stage IA1-IB1, randomized either to MIS (319 patients, 84.4% by laparoscopy and 15.6% by robotic surgery) or laparotomy (312 patients).1Ramirez PT Frumovitz M Pareja R et al.Minimally invasive versus abdominal radical hysterectomy for cervical cancer.N Engl J Med. 2018; 379: 1895-1904Crossref PubMed Scopus (937) Google Scholar Three-year disease-free survival was 91.2% in the MIS group compared to 97.1% in the open surgery group (HR 3.74; 95% CI 1.63–8.58), and the overall three-year survival was 93.8% in the MIS group and 99.0% in the open surgery group (HR 6.00; 95% CI 1.77–20.30). Although the survival in the open surgery group was higher than expected, the observed differences between the two groups are significant and concerning. As a result, the Society of Gynecologic Oncology of Canada (GOC) recommends withholding the routine use of MIS for radical hysterectomy in patients with cancer of the cervix. That being said, the study was performed in different areas of the world (Argentina, Australia, Brazil, Bulgaria, Canada [one centre], China, Colombia, India, Italy, Korea, Mexico, Peru, and United States) with well-established differences in incidence and outcome of ce