No significant difference was observed in the risk of recurrence, local recurrence, or death between patients with cervical cancer in whom a radical uterine procedure (mostly radical hysterectomy) was completed or abandoned upon intraoperative detection of positive pelvic lymph nodes. These findings from the retrospective, observational, international ABRAX study were presented by Cibula et al at the ESMO Virtual Congress 2020 (Abstract 806O).
Controversy Around Intraoperative Detection of Positive Lymph Nodes
Researchers discussed the controversy regarding the management of patients with cervical cancer who are diagnosed with positive pelvic lymph nodes intraoperatively. Current clinical practice is almost equally divided between two different types of managements. It was noted that extensive surgical dissection in the pelvis followed by pelvic radiotherapy has been linked to higher morbidity, since both treatment modalities are associated with different types of adverse events.
The team conducted the ABRAX study to evaluate whether the completion of radical hysterectomy improves outcomes in these patients. This multicenter, retrospective, cohort study comprised 515 patients who were referred for primary surgery with curative intent between 2005 and 2015 for stage IA to IIB cervical cancer and were subsequently found to have positive lymph nodes during surgery. Lymph nodes with metastasis ≥ 0.2 mm were considered positive (N1).
Patients were stratified into two subgroups according to the type of surgical management: the COMPL group included 361 patients in whom a uterine procedure was completed as planned (92.8%, radical hysterectomy; 3.9%, simple hysterectomy; 2.5%, radical trachelectomy; 0.6%, simple trachelectomy), and the ABAND group included 154 patients in whom a uterine procedure was abandoned based on intraoperative detection of lymph node positivity. Traditional prognostic markers—such as tumor size, tumor type, and disease stage—were balanced between the two groups. By propensity score matching, none of the outcome endpoints were influenced by the type of management after removal of other potentially relevant covariates. Additional treatment administered included adjuvant chemoradiation therapy in 75% of patients; combined radiotherapy in 13%; and chemotherapy alone in 17% of the COMPL group, and primary chemoradiation in 93% and primary combined radiotherapy in 7% of patients in the ABAND group.
With a median follow-up of 48.9 months, 381 (74%) patients in the overall population were disease-free. No significant differences were found between the two groups regarding the risk of recurrence (hazard ratio [HR] = 1.154, P = .446), local recurrence (HR = 0.836, P = .557), or death (HR = 1.064, P = .779). Subgroup analyses did not identify a group of patients who had a survival benefit from completing uterine surgery. In the overall study cohort, increasing International Federation of Gynecology and Obstetrics stage and tumor size ≥ 4 cm were identified as major prognostic factors associated with the risk of recurrence and poorer survival.
Based on these results from the ABRAX study, the authors concluded that completion of radical hysterectomy in patients with intraoperative detection of positive lymph nodes does not improve survival, irrespective of tumor size or type.
Therefore, the investigators suggested that if pelvic lymph node involvement is diagnosed at surgery, abandonment of planned uterine procedure should be considered and the patient should be referred to definitive chemoradiation therapy.
Disclosure: Funding for this study was provided by the Charles University in Prague and the Czech Research Council. For full disclosures of the study authors, visit oncologypro.esmo.org.The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.