Research Paper
Protective effect of pre-operative conization in patients undergoing surgical treatment for early-stage cervical cancer

https://doi.org/10.1016/j.ygyno.2022.05.014Get rights and content

Highlights

  • We investigated the survival impact of pre-operative conization on disease-free survival in early-stage cervical cancer.

  • Tumour spillage during radical hysterectomy may be prevented by pre-operative conization.

  • Pre-operative conization is associated with improved disease-free survival independently of the surgical approach.

Abstract

Objective

The aim of this study was to investigate the impact of pre-operative conization on disease-free survival (DFS) in early-stage cervical cancer.

Methods

In this population-based cohort study we analysed from clinical cancer registries to determine DFS of women with International Federation of Gynecology and Obstetrics (FIGO) stage IA1–IB1 cervical cancer with respect to conization preceding radical hysterectomy performed between January 2010 and December 2015.

Results

Out of 993 datasets available for the analysis, 235 patients met the inclusion criteria of the current study. The median follow-up was 5.4 years. During the study period, 28 (11.9%) recurrences were observed. All of these occurred in patients with FIGO stage IB1. For further evaluation, patients with FIGO IB1 tumors <2 cm were further analysed and divided into two groups, based on pre-operative conization. Pre-operative conization was associated with a reduced rate of recurrence (p = 0.007), with only three (5.2%) recurrences in this group (CO) compared to 25 recurrences (21.0%) in the group without conization (NCO) preceding radical hysterectomy. DFS was estimated at 79.0% and 94.8% in NCO and CO, respectively (p = 0.008). After adjustment for other prognostic covariates, conization remained a favourable prognostic factor for DFS (HR 0.27; 95% CI 0.08–0.93, p = 0.037). Lymph node involvement was the only unfavourable factor (HR 4.38; 95% CI 1.36–14.14, p = 0.014) in the multivariable analysis.

Conclusions

Pre-operative conization is associated with improved DFS in early-stage cervical cancer independently of the surgical approach.

Introduction

Surgical treatment of early cervical cancer has become a matter of debate in recent years, especially after the publishing of the surprising findings of the multicentre randomized Laparoscopic Approach to Cervical Cancer (LACC) trial [1]. In this trial, minimally invasive surgery led to worse outcome compared to abdominal radical hysterectomy. Mechanical manipulation of the tumour during surgery and tumour spillage in the peritoneal cavity have been discussed as potential causes for these findings [1], but further investigations are needed to confirm this hypothesis or to identify other mechanisms with a negative impact on the outcome of minimally invasive radical hysterectomy. A few recent retrospective studies suggested a protective effect of pre-operative conization before the minimally invasive surgery for early-stage cervical cancer [[2], [3], [4]]. This is most likely due to the pre-operative removal of the tumour reducing the possibility of tumour manipulation and spillage during the surgery. Notably, this protective effect of pre-operative conization has been only demonstrated in patient populations treated with minimally invasive surgery, in which the use of pneumoperitoneum is a known risk factor for recurrences [5]. To improve the understanding of the underlying mechanisms of a protective influence of pre-operative conization, further studies including patients treated with abdominal radical hysterectomy are needed.

In this study, we aimed to investigate the use of pre-operative conization to prevent recurrences in patients with cervical cancer independently of surgical approach. For this purpose, we performed an analysis of a large prospectively-maintained population-based cohort of patients with early-stage cervical cancer.

Section snippets

Materials and methods

Data on patients with cervical cancer originating from the prospectively-maintained population-based clinical cancer registries of Regensburg (Bavaria, Germany) and Magdeburg (Saxony-Anhalt, Germany) were analysed. These two high-quality population-based regional cancer registries were founded in 1991 and cover a population of more than 3 million people of Upper Palatinate, Lower Bavaria and north Saxony-Anhalt. Following a stringent protocol, these cancer registries obtain a cross-sectorial

Results

The median follow-up was 5.4 years (range 0.13–9.20 years). During the study period, 28 (11.9%) recurrences were observed. Notably, no recurrence occurred in patients with FIGO stage IA tumors; therefore, these patients were excluded from further analyses.

We further analysed the 177 patients with FIGO stage IB1 and tumour ≤2 cm after stratification for the type of pre-operative diagnosis: 58 patients (32.8%) underwent a pre-operative cervical conization, whereas in 119 (67.2%) patients, the

Discussion

In this retrospective cohort study, pre-operative conization had a favourable effect on the recurrence rates in patients with stage IB1 cervical cancer with tumour size ≤2 cm, and consequently, was associated with better DFS. These results are in accordance with some recent studies [2,4,11]. Casarin et al. found that tumour size >2 cm and pre-operative conization are important factors associated with survival in patients with early-stage cervical cancer [4]. The protective effect of

Conflict of interest

The authors declare no conflict of interest.

Author contribution

PG, carried out the study design and statistical analysis and participated in drafting the manuscript, ST, collected the data and participated in analysis of the clinical data; JM, participated in collecting the data analysis of the clinical data; MG, participated in study design and analysis of the clinical data; MK, participated in designing the study and analysis of the clinical data; GT, participated in collecting the data analysis of the clinical data; OO, participated in designing the

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