Is it time to change surgery for early-stage low-risk cervical cancer to simple hysterectomy?

다국어 초록 (Multilingual Abstract)

Radical hysterectomy has long been a standard surgical procedure for early-stage cer vicalcancer. About 80% of early-stage cer vical cancer can be treated with radical hysterectomy,and the sur vival rate after radical hysterectomy is approximately 80% or more [1]. However,since urinar y dysfunction and defecation dysfunction occur in around 40% of patientsafter radical hysterectomy, a decrease in quality of life has long been a problem [2]. Tocomplement this, a ner ve-sparing radical hysterectomy procedure has been proposed, butalthough this is a ver y reasonable surgical procedure in theor y, it is not yet clear whether ithelps reduce morbidity and quality of life [3]. Another method is to find a low-risk groupin which the risk of parametrial metastasis is negligible and sufficient tumor-free resectionmargin can be secured with simple hysterectomy and to omit parametrectomy [4]. Studiescomparing simple hysterectomy and radical hysterectomy have been discouraged due toconcerns about the decrease in sur vival rate that will occur if parametrectomy is omittedin cer vical cancer. The SHAPE trial was the first prospective randomized controlled trialcomparing simple hysterectomy and radical hysterectomy in low-risk early-stage cer vicalcancer, and demonstrated that simple hysterectomy was non-inferior to radical hysterectomyin terms of pelvic recurrence rate at 3 years [5].
In the SHAPE trial, pelvic relapse free sur vival was initially the primar y endpoint, but due toinsufficient event occurrence, it was changed to pelvic recurrence rate at 3 years. The pelvicrecurrence rate was shown to be non-inferior, but in fact, exptrapelvic recurrence and overallrecurrence were more frequent in the simple hysterectomy group, and deaths due to cer vicalcancer were also more frequent in the simple hysterectomy group even though positive lymphnode, positive resection margin and positive parametrium were more in radical hysterectomygroup. The total recurrence rate including pelvic and exprapelvic recurrence after simplehysterectomy was 4.3% in SHAPE trial. In ConCer v trial that included patients with negativeresection margin after loop electrosurgical excision procedure or conization, the totalrecurrence rate was 3.5% after simple hysterectomy in low-risk early-stage cer vical cancer[6]. The total recurrence rate was 2.9% after radical hysterectomy in SHAPE trial. It was 0.7%in all stage IB1 cer vical cancer after open radical hysterectomy in LACC trial [7]. Many studygroups are expected to conduct follow-up studies evaluating less radical surger y in the future,and exptrapelvic recurrence should also be included as a primar y endpoint.
The definition of low-risk early-stage cer vical cancer is same with the definition of low-risk disease for parametrial involvement. These criteria var y somewhat among studies, butinclude usual type histology (squamous cell carcinoma, adenocarcinoma, and adenosqumous carcinoma), tumor <2 cm, depth of invasion <10 mm, negative lymphovascular spaceinvasion, and negative lymph node metastasis [4]. In the ConCer v trial, adenocarcinoma waslimited to grade 1 and 2 [6]. In the SHPAE trial, cases with invasion depth of less than 50%on magnetic resonance imaging (MRI) were also included. Instead, lymphovascular spaceinvasion was not considered in the SHPAE trial. In fact, it is inaccurate to diagnose low-riskdisease using these conditions before surger y. It is difficult to accurately measure tumorsize and lymphvascular space invasion before surger y, and diagnosing stromal invasiondepth with MRI is also ver y inaccurate. In SHAPE trial, parametrial involvement was notedin 1.7% of patients after radical hysterectomy, but no one had parametrial involvement insimple hysterectomy. The parametrial involvement might be missed in simple hysterectomygroup because parametrectomy was not performed. To diagnose low-risk early-stage cer vicalcancer, more accurate method is needed.
The SHAPE trial did not clearly specif y ...