ASO Author Reflections: Robotic Radical Hysterectomy for Patients with Early-Stage Cervical Cancer: Oncologic Outcomes
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Robotic Radical Hysterectomy for Patients with Early-Stage Cervical Cancer: Oncologic Outcomes Vanna Zanagnolo, MD, and Alessia Aloisi, MD Department of Gynecology Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
The introduction of minimally invasive surgery (MIS) has had a dramatic impact on the health care management of endometrial and cervical cancer patients. Prior to the results of the Laparoscopic Approach to Cervical Cancer (LACC) trial1 becoming available, guidelines from the National Comprehensive Cancer Network (NCCN) and European Society of Gynaecological Oncology (ESGO) indicated that either laparotomy or MIS (laparoscopy or robotic) were acceptable approaches to radical hysterectomy in patients with early-stage (IA2–IIA) cervical cancer. The results from the LACC trial1 showing that minimally invasive radical hysterectomy had worse disease-free survival and overall survival (OS) compared with the open approach, were highly unexpected. There was some speculation regarding the use of intrauterine manipulators, CO2 gas, or intracorporeal colpotomy that might have accounted for these surprising outcomes. Nevertheless, we are looking at level A evidence and have to learn from these results, starting by critically analyzing our own data. After an early period when almost all patients who were eligible for surgery underwent MIS regardless of the histologic type and tumor diameter, and when no significant maneuvers were implemented to prevent cancer seeding, we defined specific criteria to select patients eligible for robotic radical hysterectomy and started to apply protective maneuvers.
Ó Society of Surgical Oncology 2020 First Received: 8 August 2020 Accepted: 15 August 2020 A. Aloisi, MD e-mail: [email protected]
In our analysis,2 at a median duration of follow-up of 52 months we observed a recurrence rate of 5.6%; at 4.5 years, progression-free survival (PFS) was 93.1% and OS was 95.1%. Stratifying by tumor size, PFS for tumors \ 2 cm versus tumors C 2 cm was statistically different (96.8% ± 2.3 and 87.9% ± 4.1, respectively; p = 0.01), while OS for tumors \ 2 cm versus tumors C 2 cm was 100% and 89.8% ± 4.0, respectively; p = 0.01). Stratifying by evidence of tumor at the time of robotic surgery, PFS was statistically different in women with no residual tumor after conization versus presence of tumor in the uterus at the time of surgery (100% ± 2.5 and 90.8% ± 2.8, respectively; p = 0.04). We could speculate that the robotic approach, together with some technical precautions to avoid spillage, might be safe as a primary treatment for early-stage cervical cancer, especially for tumors \ 2 cm and in cases of no evidence of disease at the time of radical hysterectomy after previous conization. Based on our own data,2 the preliminary results of an international European cohort observational study comparing MIS versus open surgery,3 and the Swedish nationwide population-based cohort study,4 we could speculate that the possible explanatio
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