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Minimally invasive surgery for radical hysterectomy in women with cervical cancer: Korean Society of Gynecologic Oncology, Korean Society of Obstetrics and Gynecology, and Korean Society of Gynecologic Endoscopy and Minimally Invasive Surgery position statement

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Abstract

On the basis of emerging data and the current understanding of minimally invasive surgery (MIS) for radical hysterectomy (RH) in women with cervical cancer, the Korean Society of Gynecologic Oncology, Korean Society of Obstetrics and Gynecology, and Korean Society of Gynecologic Endoscopy and Minimally Invasive Surgery support the following recommendations: According to the recently published phase III Laparoscopic Approach to Cervical Cancer (LACC) trial-a prospective randomized clinical trial-disease-free survival and overall survival rates of MIS RH are significantly lower than those of open RH. Gynecologic oncologists should be aware of the emerging data on MIS RH for early-stage cervical cancer. The results of the LACC trial, together with institutional data, should be discussed with patients before choosing MIS RH. MIS RH should be performed for optimal candidates according to the current practice guidelines by gynecologic oncologists who are skilled at performing MIS.
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ABSTRACT
On the basis of emerging data and the current understanding of minimally invasive surgery
(MIS) for radical hysterectomy (RH) in women with cervical cancer, the Korean Society
of Gynecologic Oncology, Korean Society of Obstetrics and Gynecology, and Korean
Society of Gynecologic Endoscopy and Minimally Invasive Surgery support the following
recommendations:
According to the recently published phase III Laparoscopic Approach to Cervical Cancer
(LACC) trial—a prospective randomized clinical trial—disease-free survival and overall
survival rates of MIS RH are signicantly lower than those of open RH.
J Gynecol Oncol. 2019 Sep;30(5):e104
https://doi.org/10.3802/jgo.2019.30.e104
pISSN 2005-0380·eISSN 2005-0399
Cooperative Group
Report
Received: Jun 2, 2019
Accepted: Jun 6, 2019
Correspondence to
Yong Beom Kim
Department of Obstetrics and Gynecology,
Seoul National University Bundang Hospital,
82 Gumi-ro 173beon-gil, Bundang-gu,
Seongnam 13620, Korea.
E-mail: ybkimlh@snubh.org
This statement asserts the official position of
the Korean Society of Gynecologic Oncology,
Korean Society of Obstetrics and Gynecology
and Korean Society of Gynecologic Endoscopy
and Minimally Invasive Surgery, and has no
legal validity for clinical decisions.
Copyright © 2019. Asian Society of
Gynecologic Oncology, Korean Society of
Gynecologic Oncology
This is an Open Access article distributed
under the terms of the Creative Commons
Attribution Non-Commercial License (https://
creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted non-commercial
use, distribution, and reproduction in any
medium, provided the original work is properly
cited.
ORCID iDs
Miseon Kim
https://orcid.org/0000-0002-5118-9275
Tae-Wook Kong
https://orcid.org/0000-0002-9007-565X
Sunghoon Kim
https://orcid.org/0000-0002-1645-7473
Seung Cheol Kim
https://orcid.org/0000-0002-5000-9914
Yong Beom Kim
https://orcid.org/0000-0003-1196-369X
Miseon Kim ,1 Tae-Wook Kong ,2 Sunghoon Kim ,3 Seung Cheol Kim ,4
Yong Beom Kim ,5 Jae-Weon Kim ,6 Jeong-Yeol Park ,7 Dong Hoon Suh ,5
Seung-Hyuk Shim ,8 Keun Ho Lee ,9 Sung Jong Lee ,9 Jae-Kwan Lee ,10
Myong Cheol Lim 11
1
Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University School of
Medicine, Seoul, Korea
2
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ajou University School of
Medicine, Suwon, Korea
3Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
4Department of Obstetrics and Gynecology, Ewha Womans University College of Medicine, Seoul, Korea
5Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
6Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
7
Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center,
Seoul, Korea
8
Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University
School of Medicine, Seoul, Korea
9
Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic
University of Korea, Seoul, Korea
1 0Department of Obstetrics and Gynecology, Korea University Medical Center, Korea University College of
Medicine, Seoul, Korea
1 1Department of Obstetrics and Gynecology, Division of Tumor Immunology, Center for Uterine Cancer, and
Center for Clinical Trials, National Cancer Center, Goyang, Korea
Minimally invasive surgery for
radical hysterectomy in women
with cervical cancer: Korean Society
of Gynecologic Oncology, Korean
Society of Obstetrics and Gynecology,
and Korean Society of Gynecologic
Endoscopy and Minimally Invasive
Surgery position statement
Provisional
Provisional
Jae-Weon Kim
https://orcid.org/0000-0003-1835-9436
Jeong-Yeol Park
https://orcid.org/0000-0003-2475-7123
Dong Hoon Suh
https://orcid.org/0000-0002-4312-966X
Seung-Hyuk Shim
https://orcid.org/0000-0001-8043-2257
Keun Ho Lee
https://orcid.org/0000-0001-9005-7796
Sung Jong Lee
https://orcid.org/0000-0002-6077-2649
Jae-Kwan Lee
https://orcid.org/0000-0003-3101-6403
Myong Cheol Lim
https://orcid.org/0000-0001-8964-7158
Conflict of Interest
No potential conflict of interest relevant to this
article was reported.
Author Contributions
Conceptualization: K.M., K.T.W., K.S., K.S.C.,
K.Y.B., K.J.W., P.J.Y., S.D.H., S.S.H., L.K.H.,
L.S.J., L.J.K., L.M.C.; Supervision: K.S.C., K.Y.B.;
Writing - original draft: K.M., K.Y.B.; Writing
- review & editing: K.M., K.T.W., K.S., K.S.C.,
K.Y.B., K.J.W., P.J.Y., S.D.H., S.S.H., L.K.H.,
L.S.J., L.J.K., L.M.C.
Gynecologic oncologists should be aware of the emerging data on MIS RH for early-stage
cervical cancer.
The results of the LACC trial, together with institutional data, should be discussed with
patients before choosing MIS RH.
MIS RH should be performed for optimal candidates according to the current practice
guidelines by gynecologic oncologists who are skilled at performing MIS.
Keywords: Uterine Cervical Neoplasms; Hysterectomy; Minimally Invasive Surgical Procedures;
Laparoscopy; Laparotomy
Cervical cancer is the 4th most commonly diagnosed cancer (6.6% of the total cases) and
the 4th leading cause of cancer death (7.5% of the total cancer deaths) in women worldwide
[1]. In Korea, cervical cancer is the 7th most common female malignancy, and 3,582 cases
of cervical cancers were newly diagnosed in 2015 [2]. According to National Comprehensive
Cancer Network guidelines, the following are considered as standard surgical treatments
for early-stage cervical cancers: a modied radical hysterectomy with pelvic lymph node
dissection (PLND) in International Federation of Gynecology and Obstetrics (2009; FIGO)
stage IA1 with lympho-vascular space invasion (LVSI) and IA2, and a RH with PLND with/
without para-aortic lymph node dissection in FIGO stage IB1 and IIA1 [3]. Previous iterations
of the guidelines had indicated that RH could be performed either via open laparotomy or
via minimally invasive surgery (MIS) with laparoscopic approaches (which can be robotically
assisted) [3-5]. The Korean Society of Gynecologic Oncology also stated that laparoscopic or
robotic RH can be performed in patients with stage IB-IIA cervical cancer in the 3rd edition
of the practice guidelines for management of cervical cancer in 2016 [4].
A recently published prospective randomized trial demonstrated that MIS RH is associated
with lower rates of disease-free survival (DFS) and overall survival (OS) than open RH is [6].
This phase III Laparoscopic Approach to Cervical Cancer (LACC) trial (Clinicaltrials.gov
Identier: NCT00614211) was designed for the denitive comparison of survival outcomes
in patients with early-stage cervical cancer undergoing MIS RH and open RH. A total of 631
women with 2009 FIGO stage IA1 (with LVSI), IA2, and 1B1 cervical cancer were enrolled
during the 2008–2017 period. Among them, 319 and 312 patients were randomly assigned
to MIS RH group and open RH group, respectively. Median follow-up period was 2.5 (range,
0–6.3) years. The DFS rate aer 4.5 years was 97.6% (95% condence inter val [CI]=94.1–99.0)
in the open RH group and 87.1% (95% CI=81.0–91.3) in the MIS RH group (per-protocol
population; p=0.88 for non-inferiority). In patients treated with MIS RH, worse DFS (hazard
ratio [HR]=3.74; 95% CI=1.63–8.58; p=0.002) and OS (HR=6.0; 95% CI=1.77–20.3, p=0.04)
rates were observed aer 3 years.
The ndings of this LACC trial are consistent with those of a retrospective study based on the
data from National Cancer Database (NCDB) in the United States [7]. According to NCDB,
during the 2010–2013 period, 2,461 women underwent RH for FIGO stage IA2 or IB1 cervical
cancer. Among them, 1,225 (49.8%) underwent MIS RH and 1,236 (50.2%) underwent open
RH. Median follow-up period was 45 months. With regard to results, a higher risk of all-
cause mortality (HR=1.65, 95% CI=1.22–2.22; p=0.002) was observed in the MIS RH group.
Additionally, authors showed that the adoption of MIS was associated with a decline in the
4-year relative survival rate of 0.8% per year aer 2006 (95% CI=0.3–1.4; p=0.01 for change
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of trend) by interrupted time-series analysis of the data from the Surveillance, Epidemiology,
and End Results (SEER) program database for the 2000–2010 period.
Previously, several non-randomized studies have shown perioperative advantages [8-12] and
similar oncologic outcomes of MIS RH compared to those of open RH [13-16]. However, the
LACC trial is the rst randomized study which compared the survival outcomes of MIS and
open RH in patients with cervical cancer. Although some controversies regarding insucient
surgeons’ prociency and a lack of eort to minimize tumor spillage in the MIS group still
surround this study, the clinical impact of this LACC trial results cannot be denied.
All cervical cancer patients scheduled to undergo RH should be informed about the outcome
of this LACC trial. MIS RH should be chosen to treat proper candidates according to the
current practice guidelines, and it should be performed by gynecologic oncologists who are
skilled at performing MIS. Furthermore, establishment of optimal indication for performing
MIS based on the tumor size and surgical methods to minimize tumor destruction or
intraperitoneal spillage during colpotomy is required to ensure the oncologic safety of MIS in
cervical cancer.
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... Minimally invasive surgery involves less surgical trauma, faster hospital discharge and decreased postoperative pain, with less time needed for returning to a normal life routine [10][11][12][13][14]. It is essential to teach and train laparoscopy in every surgical residency, especially in gynecological surgery, in which a less invasive approach significantly improves the postsurgical quality of life of both fertile-age and postmenopausal women [13,[15][16][17][18]. ...
... Minimally invasive surgery involves less surgical trauma, faster hospital discharge and decreased postoperative pain, with less time needed for returning to a normal life routine [10][11][12][13][14]. It is essential to teach and train laparoscopy in every surgical residency, especially in gynecological surgery, in which a less invasive approach significantly improves the postsurgical quality of life of both fertile-age and postmenopausal women [13,[15][16][17][18]. ...
Full-text available
Article
Background and Objectives: The type of instrumentation used during laparoscopic surgery might impact on the learning curve of resident surgeons. The aim of this study was to investigate differences in operator satisfaction and surgical outcomes between tissue sealers and classic bipolar instruments during gynecological laparoscopies performed by residents. Materials and Methods: A prospective cohort study conducted at two tertiary university hospitals between March 2019 and March 2021, on consecutive procedures: salpingo-oophorectomies (Group 1) and salpingectomies (Group 2), subdivided according to the utilized device: radiofrequency tissue sealers (Groups A1 and A2) or bipolar forceps (Groups B1 and B2). Results: 80 procedures were included. Concerning salpingo-oophorectomies, better visibility (8.4 ± 0.8 vs. 7.3 ± 0.9; p = 0.03), reduced difficulty (5.4 ± 1.2 vs. 7.0 ± 1.4; p = 0.02), improved overall satisfaction (9.2 ± 0.4 vs. 7.6 ± 1.0; p = 0.02) and reduced procedure time (7.8 ± 3.4 vs. 12.6 ± 3.1; p = 0.01) were reported by residents using tissue sealers. Intraoperative blood loss (12.2 ± 4.7 mL vs. 33.2 ± 9.7 mL; p = 0.01) and 24 h postoperative pain (4.5 ± 1.1 vs. 5.7 ± 1.8; p = 0.03) were lower in group A1 than B1. For salpingectomies, a significant reduction in duration was found in A2 compared to B2 (7.2 ± 3.4 min vs. 13.8 ± 2.2 min; p = 0.02). Tissue sealers enhanced visibility (8.1 ± 1.1 vs. 6.7 ± 1.4; p = 0.01), difficulty (6.5 ± 1.1 vs. 7.5 ± 0.9; p = 0.04) and improved satisfaction (9.3 ± 0.5 vs. 7.5 ± 0.6; p = 0.01). Moreover, hemoglobin loss and postoperative pain were reduced in A2 relative to B2 [(8.1 ± 4.2 % vs. 4.5 ± 1.1%; p = 0.02) and (5.1 ± 0.9 vs. 4.1 ± 0.8; p = 0.03), respectively] Conclusions: The use of sealing devices by residents was related to reduced difficulty as well improved visibility and overall satisfaction, with improved surgical outcomes.
... After the publication of the LACC trial, however, all cervical cancer patients scheduled to undergo RH were informed about the LACC trial results together with institutional data [28]. MIS RH was recommended only for 2009 FIGO stage IB1 patients with cervical tumor size ≤2 cm on preoperative imaging after our previous reports [17,18]. ...
Full-text available
Article
Objective To compare survival outcomes of minimally invasive surgery (MIS) and open surgery for radical hysterectomy (RH) in early cervical cancer patients with histologic subtypes of usual-type adenocarcinoma and adenosquamous carcinoma. Methods From two centers' cervical cancer cohorts, patients with 2009 FIGO stage IB1–IB2 who underwent RH between 2007 and 2020 were retrospectively identified. Patients with usual-type adenocarcinoma and adenosquamous carcinoma were included in the analysis after pathologic review according to the updated World Health Organization Classification of Tumors. Clinicopathologic characteristics and survival outcomes were compared in terms of open surgery or MIS. Results This study included 161 patients. No significant differences were noted in overall survival (OS; P = 0.241) and disease-free survival (DFS; P = 0.156) between patients with usual-type adenocarcinoma (n = 136) and those with adenosquamous carcinoma (n = 25). MIS RH group (n = 99) had a significantly smaller tumor size (P < 0.001), lesser pathologic parametrial invasion (P = 0.001), and lesser lymph node metastasis (P < 0.001) than open RH group (n = 62). MIS and open RH groups showed similar OS (P = 0.201) and 3-year DFS rate (87.9% vs. 75.1%; P = 0.184). In multivariate analysis, worse DFS was not associated with MIS (P = 0.589) but was associated with pathologic parametrial invasion (adjusted HR, 3.41; 95% CI, 1.25–9.29; P = 0.016). Consistent results were observed among patients with usual-type adenocarcinoma; MIS was not associated with worse DFS. Conclusions Comparable survival outcomes were found for MIS and open RH in early-stage cervical usual-type adenocarcinoma and adenosquamous carcinoma. Although MIS RH was not a poor prognostic factor, pathologic parametrial invasion was significantly associated with worse DFS in cervical usual-type adenocarcinoma and adenosquamous carcinoma.
... Therefore we wrote: "Laparoscopy or robot-assisted surgery may be performed by a skilled gynecologic cancer specialist in patients who can achieve oncological safety, based on the tumor size and the development of surgical skills to minimize intraperitoneal metastasis of cervical cancer. Laparoscopy or robot-assisted surgery must be performed after the patient and physician have fully discussed the advantages and disadvantages of the surgical approaches" [18,19]. ...
Article
The sociomedical environment is changing. In the traditional physician-patient relationship, the physician was authoritative and the patient was obedient. The contractual relationship featured patient consent to the physician's decision. Today, the physician must explain fully the planned medical treatment, and any alternative, to the patient, who has the right to choose her treatment after considering the benefits and side-effects. The Korean Society of Gynecologic Oncology thus decided to standardize the surgical consent forms to meet the legal requirements of modern medicine, improve patient understanding of the surgical details, and protect medical staff from legal disputes. To determine the format and content, subcommittees for each cancer type collected and reviewed all relevant articles and the current consent forms of domestic medical institutions. After several meetings, 16 basic items to be included for each type of gynecologic cancer were selected. Also, to help patients understand the surgical details, figures were included. The revised forms were legally reviewed in terms of the appropriateness of the format and content. We also developed English versions to provide adequate information for foreign patients. We hope that these efforts will promote trust between patients and physicians, and contribute to effective treatment by laying a foundation of mutual respect.
... Therefore we wrote: "Laparoscopy or robotassisted surgery may be performed by a skilled gynecologic cancer specialist in patients who can achieve oncological safety, based on the tumor size and the development of surgical skills to minimize intraperitoneal metastasis of cervical cancer. Laparoscopy or robot-assisted surgery must be performed after the patient and physician have fully discussed the advantages and disadvantages of the surgical approaches" [18,19]. ...
Article
The sociomedical environment is changing. In the traditional physician-patient relationship, the physician was authoritative and the patient was obedient. The contractual relationship featured patient consent to the physician's decision. Today, the physician must explain fully the planned medical treatment, and any alternative, to the patient, who has the right to choose her treatment after considering the benefits and side-effects. The Korean Society of Gynecologic Oncology (KSGO) thus decided to standardize the surgical consent forms to meet the legal requirements of modern medicine, improve patient understanding of the surgical details, and protect medical staff from legal disputes. To determine the format and content, subcommittees for each cancer type collected and reviewed all relevant articles and the current consent forms of domestic medical institutions. After several meetings, 16 basic items to be included for each type of gynecologic cancer were selected. Also, to help patients understand the surgical details, figures were included. The revised forms were legally reviewed in terms of the appropriateness of the format and content. We also developed English versions to provide adequate information for foreign patients. We hope that these efforts will promote trust between patients and physicians, and contribute to effective treatment by laying a foundation of mutual respect.
... Before the publication of the LACC trial, the surgical approach was mainly determined by the surgeon's preference. However, after that trial, all cervical cancer patients scheduled to undergo RH were informed about the LACC trial results, together with institutional data [18]. Accordingly, the implementation rate of primary MIS RH significantly decreased after the LACC trial: MIS RH was only considered among 2009 FIGO stage IB1 patients with cervical tumor size ≤2 cm, based on our previous reports [12,19]. ...
Article
Objective To ascertain whether cervical conization before radical hysterectomy (RH) has a protective effect on survival outcomes in early cervical cancer, taking into account the surgical approach. Methods From cervical cancer cohorts of two institutions, we identified node-negative, margin-negative, parametria-negative, 2009 FIGO stage IB1 cervical cancer patients who received primary Type C RH between July 2006 and June 2020. Patients were divided into conization group (n = 144) and control group (n = 434). We conducted three independent 1:1 propensity score matching processes for histology, lymphovascular space invasion, cervical tumor size, and surgical approach (all patients, those who underwent open surgery, and those who underwent minimally invasive surgery [MIS]). Survival outcomes were compared. Results Overall, the conization group had less cervical tumor size and received MIS more frequently (P = 0.010) and adjuvant treatment less often (P = 0.002) versus the controls. After matching, the conization group showed significantly better disease-free survival (DFS) versus control (3-year DFS rate, 94.2% vs. 86.3%; P = 0.012), but similar overall survival. Among the open RH matched patients (n = 96), no difference in DFS was observed between the conization and control groups (P = 0.984). In contrast, among the MIS RH matched patients (n = 192), the conization group showed significantly better DFS versus control (3-year DFS rate, 95.7% vs. 82.9%; P = 0.005). In multivariate analysis adjusting for cervical tumor size and adjuvant treatment, conization was identified as an independent favorable prognostic factor for DFS (adjusted HR, 0.318; 95% CI, 0.134–0.754; P = 0.009). Conclusions Preoperative cervical conization might reduce the disease recurrence rate in early cervical cancer patients who undergo primary MIS RH.
... Further well-designed confirmatory prospective studies are warranted to identify optimal candidates for MIS RH. Until then, physicians must discuss with their early cervical cancer patients regarding surgical approach plans for RH [18]. It would thus be a great help if an intuitive and precise decision-aid tool, which estimates recurrence and mortality rates by surgical approach, is developed. ...
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We purposed to develop machine learning models predicting survival outcomes according to the surgical approach for radical hysterectomy (RH) in early cervical cancer. In total, 1056 patients with 2009 FIGO stage IB cervical cancer who underwent primary type C RH by either open or laparoscopic surgery were included in this multicenter retrospective study. The whole dataset consisting of patients’ clinicopathologic data was split into training and test sets with a 4:1 ratio. Using the training set, we developed models predicting the probability of 5-year progression-free survival (PFS) and overall survival (OS) with tenfold cross validation. The developed models were validated in the test set. In terms of predictive performance, we measured the area under the receiver operating characteristic curve (AUC) values. The logistic regression models comprised of preoperative variables yielded AUCs of 0.679 and 0.715 for predicting 5-year PFS and OS rates, respectively. Combining both logistic regression and multiple machine learning models, we constructed hybrid ensemble models, and these models showed much improved predictive performance, with 0.741 and 0.759 AUCs for predicting 5-year PFS and OS rates, respectively. We successfully developed models predicting disease recurrence and mortality after primary RH in patients with early cervical cancer. As the predicted value is calculated based on the preoperative factors, such as the surgical approach, these ensemble models would be useful for making decisions when choosing between open or laparoscopic RH.
... It is worthy to note that many studies have shown that tumor size, surgical volume, surgery approach (the use of Uterine manipulator, colpotomy, circulating CO 2 , squeezing the cervix), the standardization of surgery, whether cervical cancer surgery was performed by qualified doctors, etc., affected the outcomes of surgery and OS as well as DFS. [3,12,[39][40][41][42][43][44][45][46][47][48][49][50][51][52] For example, Magrina et al. first compared the perioperative results of patients undergoing radical hysterectomy by robotics, laparoscopy, and laparotomy and found that there was no significant difference in the mean number of removed lymph nodes among the three surgery approaches. [4] Querleu et al. retrospectively analyzed patients undergoing radical hysterectomy from 2004 to 2008 and found that surgery at high-volume centers is associated with decreased local recurrence risk, lower overall mortality, and improved survival. ...
Article
Cervical cancer surgery has a history of more than 100-years whereby it has transitioned from the open approach to minimally invasive surgery (MIS). From the era of clinical exploration and practice, minimally invasive gynecologic surgeons have never ceased to explore new frontiers in the field of gynecologic surgery. MIS has fewer postoperative complications, including reduction of treatment-related morbidity and length of hospital stay than laparotomy; this forms the mainstay of treatment for early-stage cervical cancer. However, in November 2018, the New England Journal of Medicine had published two clinical studies on cervical cancer surgery (Laparoscopic Approach to Cervical Cancer [LACC]). Following these publications, laparoscopic surgery for early-stage cervical cancer has come under intense scrutiny and negative perceptions. Many studies began to explore the concept of standardized surgery for early-stage cervical cancer. In this article, we performed a review of the history of cervical cancer surgery, outlined the standardization of cervical cancer surgery, and analyzed the current state of affairs revolving around cervical cancer surgery in the post-LACC era.
... Korean Society of Gynecologic Oncology (KSGO), one of representative society in Korea, stated that all cervical cancer patients scheduled to undergo radical hysterectomy should be informed about the results of the LACC trial together with institutional data before choosing MIS. Furthermore, KSGO emphasized that establishment of optimal indication for MIS based on the tumor size and surgical methods to minimize tumor destruction or intraperitoneal spillage during colpotomy is required to ensure the oncologic safety of MIS in cervical cancer [4]. ...
... Its role in endometrial cancer is well established [8]. After the publication of LACC trial use of robotic-assisted surgery for cervical cancer has been under a shadow [9][10][11]. In ovarian cancer, there is a limited role for robotic surgery, mainly for early tumors that can be removed without rupture in an endobag, completion staging, and also select advanced ovarian tumors after neoadjuvant chemotherapy. ...
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Robotic-assisted surgery has a shorter learning curve enabling the surgeons to do complex surgeries in a minimally invasive way. This study analyzed how the time taken for robotic-assisted procedures in gynecology and gynecologic oncology has changed over the years in a university teaching institution. Details were taken from a prospectively maintained electronic database after obtaining permission from the hospital ethics committee. All patients who underwent robotic surgery for gynecologic problems at this center from February 2015 till December 2019 were included. The clinical, perioperative, postoperative and pathologic details were collected from the prospectively maintained database. To analyze quantitative data, student t test was used. Chi-square test was performed to compare categorical variables. 655 patients underwent robotic-assisted surgery during this period. The majority of the patients underwent surgery for uterine cancer (49%). There was a significant improvement in total surgical time (250 vs. 165 min), docking time (12.6 vs 8.9 min), and console time (130 vs. 95 min) between the first and second year (2015–16). The next 2 years (2017 and 18) did not show a significant decrease in the total surgery time and console time, but docking times improved in 2017 (5.5 vs 8.5 min) compared to 2016. In 2019, there was a significant improvement in all surgical times compared to previous years. This study shows that robotic surgery has a lot of scope for improvement in surgical performance beyond its first and second years. The surgical performance as seen from the improved surgical times keeps on improving even after many years
... To address the potential risks of MIS for gynecological cancer, many researchers have suggested and hypothesized possible mechanisms that contribute to worse prognosis, thereby assisting in minimizing tumor dissemination during surgery [70][71][72][73][74][75][76][77][78]. Most hypotheses are mostly inconclusive and require larger randomized controlled trials. ...
Radical hysterectomy (RH) is the standard treatment for early stage cervical cancer, but the surgical approach for locally bulky-size cervical cancer (LBS-CC) is still unclear. We retrospectively compared the outcomes of women with LBS-CC treated with neoadjuvant chemotherapy (NACT) and subsequent RH between the robotic (R-RH) and abdominal approaches (A-RH). Between 2012 and 2014, 39 women with LBS-CC FIGO (International Federation of Gynecology and Obstetrics) stage IB2–IIB were treated with NACT-R-RH (n = 18) or NACT-A-RH (n = 21). Surgical parameters and prognosis were compared. Patient characteristics were not significantly different between the groups, but the NACT-R-RH group had significantly more patients with FIGO stage IIB disease, received multi-agent-based NACT, and had a lower percentage of deep stromal invasion than the NACT-A-RH group. After NACT-R-RH, surgical parameters were better, but survival outcomes, such as disease-free survival (DFS) and overall survival (OS), were significantly worse. On multivariate analysis, FIGO stage IIB contributed to worse DFS (p = 0.003) and worse OS (p = 0.012) in the NACT-A-RH group. Women with LBS-CC treated with NACT-R-RH have better perioperative outcomes but poorer survival outcomes compared with those treated with NACT-A-RH. Thus, patients with FIGO stage IIB LBS-CC disease might not be suitable for surgery after multi-agent-based NACT.
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Background The possible advantages of laparoscopic radical hysterectomy (LRH) versus open radical hysterectomy (RH) have not been well reviewed systematically. The aim of this study was to systematically review the comparative effectiveness between LRH and RH in the treatment of cervical cancer based on the evaluation of the Perioperative outcomes, oncological clearance, complications and long-term outcomes. Methods The systematic review was conducted by searching PubMed, MEDLINE, EMBASE, the Cochrane Library and BIOSIS databases. All original studies that compared LRH with RH were included for critical appraisal. Data were pooled and analyzed. Results A total of twelve original studies that compared LRH (n = 754) with RH (n = 785) in patients with cervical cancer fulfilled quality criteria were selected for review and meta-analysis. LRH compared with RH was associated with a significant reduction of intraoperative blood loss (weighted mean difference = −268.4 mL (95 % CI −361.6, −175.1; p < 0.01), a reduced risk of postoperative complications (OR = 0.46; 95 % CI 0.34–0.63) and shorter hospital stay (weighted mean difference = −3.22 days; 95 % CI–4.21, −2.23 days; p < 0.01). These benefits were at the cost of longer operative time (weighted mean difference = 26.9 min (95 % CI 8.08–45.82). The rate of intraoperative complications was similar in the two groups. Lymph nodes yield and positive resection margins were similar between the two groups. There were no significant differences in 5-year overall survival (HR 0.91, 95 % CI 0.48–1.71; p = 0.76) and 5-year disease-free survival (hazard ratio [HR] 0.97, 95 % CI 0.56–1.68; p = 0.91). Conclusions LRH shows better short term outcomes compared with RH in patients with cervical cancer. The oncologic outcome and 5-year survival were similar between the two groups.
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Objective To investigate the incidence and trends of cervical (C53), endometrial (C54.1), and ovarian cancer (C56) among Korean females between 1999 and 2015. Methods The incidence of the three major gynecological cancers between 1999 and 2015 was analyzed based on the data from the Korea Central Cancer Registry. The age-standardized rates (ASRs) and the annual percent changes (APCs) for each site were calculated. Results The absolute incidence rates of the three major gynecological cancers increased from 6,394 in 1999 to 8,288 in 2015. ASR for gynecologic cancer decreased from 23.7 per 100,000 in 1999 to 21.1 in 2015. This was mainly due to a definitive decrease in the incidence of cervical cancer, which recorded an APC of −3.7%. The trends of APC for gynecologic cancer were variable, being −1.36% between 1999 and 2006 and −0.11% between 2006 and 2015. A definitive but variable increase was noted for endometrial cancer, and the APC for this cancer was 7.4% between 1999 and 2009 and 3.5% between 2009 and 2015. The incidence of ovarian cancer gradually increased, with an APC of 1.8% between 1999 and 2015. Conclusion Overall, ASRs and APCs for the three major gynecological cancers are decreasing, with a recent reduction in the width of the change. However, there has been a progressive increase in the incidence of endometrial and ovarian cancers.
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Background There are limited data from retrospective studies regarding whether survival outcomes after laparoscopic or robot-assisted radical hysterectomy (minimally invasive surgery) are equivalent to those after open abdominal radical hysterectomy (open surgery) among women with early-stage cervical cancer. Methods In this trial involving patients with stage IA1 (lymphovascular invasion), IA2, or IB1 cervical cancer and a histologic subtype of squamous-cell carcinoma, adenocarcinoma, or adenosquamous carcinoma, we randomly assigned patients to undergo minimally invasive surgery or open surgery. The primary outcome was the rate of disease-free survival at 4.5 years, with noninferiority claimed if the lower boundary of the two-sided 95% confidence interval of the between-group difference (minimally invasive surgery minus open surgery) was greater than −7.2 percentage points (i.e., closer to zero). Results A total of 319 patients were assigned to minimally invasive surgery and 312 to open surgery. Of the patients who were assigned to and underwent minimally invasive surgery, 84.4% underwent laparoscopy and 15.6% robot-assisted surgery. Overall, the mean age of the patients was 46.0 years. Most patients (91.9%) had stage IB1 disease. The two groups were similar with respect to histologic subtypes, the rate of lymphovascular invasion, rates of parametrial and lymph-node involvement, tumor size, tumor grade, and the rate of use of adjuvant therapy. The rate of disease-free survival at 4.5 years was 86.0% with minimally invasive surgery and 96.5% with open surgery, a difference of −10.6 percentage points (95% confidence interval [CI], −16.4 to −4.7). Minimally invasive surgery was associated with a lower rate of disease-free survival than open surgery (3-year rate, 91.2% vs. 97.1%; hazard ratio for disease recurrence or death from cervical cancer, 3.74; 95% CI, 1.63 to 8.58), a difference that remained after adjustment for age, body-mass index, stage of disease, lymphovascular invasion, and lymph-node involvement; minimally invasive surgery was also associated with a lower rate of overall survival (3-year rate, 93.8% vs. 99.0%; hazard ratio for death from any cause, 6.00; 95% CI, 1.77 to 20.30). Conclusions In this trial, minimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open abdominal radical hysterectomy among women with early-stage cervical cancer. (Funded by the University of Texas M.D. Anderson Cancer Center and Medtronic; LACC ClinicalTrials.gov number, NCT00614211.)
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Clinical practice guidelines for gynecologic cancers have been developed by academic society from several countries. Each guideline reflected their own insurance system and unique medical environment, based on the published evidence. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to develop the third edition of the guidelines in an advanced format based on evidence-based medicine, embracing up-to-date clinical trials and qualified Korean data. These guidelines cover strategies for diagnosis and treatment of primary and recurrent cervical cancer. The committee members and many gynecologic oncologists derived key questions through discussions, and a number of relevant scientific literature were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, along with the details. The objective of these practice guidelines is to establish standard policies on issues in clinical practice related to the management in cervical cancer based on the results in published papers to date and the consensus of experts as a KSGO Consensus Statement.
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Cervical cancer is a malignant epithelial tumor that forms in the uterine cervix. Most cases of cervical cancer are preventable through human papilloma virus (HPV) vaccination, routine screening, and treatment of precancerous lesions. However, due to inadequate screening protocols in many regions of the world, cervical cancer remains the fourth-most common cancer in women globally. The complete NCCN Guidelines for Cervical Cancer provide recommendations for the diagnosis, evaluation, and treatment of cervical cancer. This manuscript discusses guiding principles for the workup, staging, and treatment of early stage and locally advanced cervical cancer, as well as evidence for these recommendations. For recommendations regarding treatment of recurrent or metastatic disease, please see the full guidelines on NCCN.org.
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Background Minimally invasive surgery was adopted as an alternative to laparotomy (open surgery) for radical hysterectomy in patients with early-stage cervical cancer before high-quality evidence regarding its effect on survival was available. We sought to determine the effect of minimally invasive surgery on all-cause mortality among women undergoing radical hysterectomy for cervical cancer. Methods We performed a cohort study involving women who underwent radical hysterectomy for stage IA2 or IB1 cervical cancer during the 2010–2013 period at Commission on Cancer–accredited hospitals in the United States. The study used inverse probability of treatment propensity-score weighting. We also conducted an interrupted time-series analysis involving women who underwent radical hysterectomy for cervical cancer during the 2000–2010 period, using the Surveillance, Epidemiology, and End Results program database. Results In the primary analysis, 1225 of 2461 women (49.8%) underwent minimally invasive surgery. Women treated with minimally invasive surgery were more often white, privately insured, and from ZIP Codes with higher socioeconomic status, had smaller, lower-grade tumors, and were more likely to have received a diagnosis later in the study period than women who underwent open surgery. Over a median follow-up of 45 months, the 4-year mortality was 9.1% among women who underwent minimally invasive surgery and 5.3% among those who underwent open surgery (hazard ratio, 1.65; 95% confidence interval [CI], 1.22 to 2.22; P=0.002 by the log-rank test). Before the adoption of minimally invasive radical hysterectomy (i.e., in the 2000–2006 period), the 4-year relative survival rate among women who underwent radical hysterectomy for cervical cancer remained stable (annual percentage change, 0.3%; 95% CI, −0.1 to 0.6). The adoption of minimally invasive surgery coincided with a decline in the 4-year relative survival rate of 0.8% (95% CI, 0.3 to 1.4) per year after 2006 (P=0.01 for change of trend). Conclusions In an epidemiologic study, minimally invasive radical hysterectomy was associated with shorter overall survival than open surgery among women with stage IA2 or IB1 cervical carcinoma. (Funded by the National Cancer Institute and others.)
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This article provides a status report on the global burden of cancer worldwide using the GLOBOCAN 2018 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer, with a focus on geographic variability across 20 world regions. There will be an estimated 18.1 million new cancer cases (17.0 million excluding nonmelanoma skin cancer) and 9.6 million cancer deaths (9.5 million excluding nonmelanoma skin cancer) in 2018. In both sexes combined, lung cancer is the most commonly diagnosed cancer (11.6% of the total cases) and the leading cause of cancer death (18.4% of the total cancer deaths), closely followed by female breast cancer (11.6%), prostate cancer (7.1%), and colorectal cancer (6.1%) for incidence and colorectal cancer (9.2%), stomach cancer (8.2%), and liver cancer (8.2%) for mortality. Lung cancer is the most frequent cancer and the leading cause of cancer death among males, followed by prostate and colorectal cancer (for incidence) and liver and stomach cancer (for mortality). Among females, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death, followed by colorectal and lung cancer (for incidence), and vice versa (for mortality); cervical cancer ranks fourth for both incidence and mortality. The most frequently diagnosed cancer and the leading cause of cancer death, however, substantially vary across countries and within each country depending on the degree of economic development and associated social and life style factors. It is noteworthy that high‐quality cancer registry data, the basis for planning and implementing evidence‐based cancer control programs, are not available in most low‐ and middle‐income countries. The Global Initiative for Cancer Registry Development is an international partnership that supports better estimation, as well as the collection and use of local data, to prioritize and evaluate national cancer control efforts. CA: A Cancer Journal for Clinicians 2018;0:1‐31. © 2018 American Cancer Society