Minimally Inv Surgery for Cervical

[scarbrtj]

Cervical ca has become a rare-ish disease (in the US breast ca is about 20x more common) so one doesn't see that many trials/reports these days, esp in NEJM. But it's interesting enough I thought I would post as it's been in news a lot over last week. The MDACC trial was stopped early the result was so significant. (Most cervical patients I see have the minimally inv surgery IMHO.)

Maybe don't trust in robots.

Surgery in Cervical Cancer
Survival after Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer
Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer

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[medgator]

Yup... a contrast to prostate where robot outcomes don't seem as bad compared to open (in the right high-volume hands) and seem to be better in terms of post op recovery

 

[evilbooyaa]

Relevant. Proponents will say it's due to the learning curve, and that in THEIR skilled hands, outcomes feel similar, but it's certainly concerning.

 

[seper]

Have not read the full paper, but can confirm: specimens from radical robotic hysterectomies are much skimpier than it used to be in the open era.

 

[emt409]

Relevant. Proponents will say it's due to the learning curve, and that in THEIR skilled hands, outcomes feel similar, but it's certainly concerning.

Yup, we know ALL the other gyn onc surgeons in the field are MUCH more skilled than the MDA gync onc surgeons... /s

I bet we see similar results published for endometrial in a few years.

 

[ramsesthenice]

Relevant. Proponents will say it's due to the learning curve, and that in THEIR skilled hands, outcomes feel similar, but it's certainly concerning.

I would have thought so too but at least at my current and former institutions (both of which have robots) they have drastically changed their practice because of this publication. I think they realistically acknowledge that there are more than enough early stage endometrial cases for the robot that they don't need to try to defend the results for cervical. There are very logical reasons that getting too cute surgically could be a bad idea for some diseases like cervical cancer which are very aggressive locally.

 

[emt409]

Our gyn onc's shat all over the study...still doing robot-assisted surgeries. IMHO, all 1B1 and maybe 1A2 patients need adjuvant chemo or chemoRT.

 

[OTN]

Our gyn onc's shat all over the study...still doing robot-assisted surgeries. IMHO, all 1B1 and maybe 1A2 patients need adjuvant chemo or chemoRT.

I wonder what the rea$on could be.

 

[evilbooyaa]

Our gyn onc's shat all over the study...still doing robot-assisted surgeries. IMHO, all 1B1 and maybe 1A2 patients need adjuvant chemo or chemoRT.

What were the specific criticisms?

That MD Anderson Gyn-oncs are horribly trained and all other places Gyn-oncs are obviously better than those at the Mecca?

 

[seper]

Once again, robotic specimens appear to be smaller than ones from open radhys. Less tissue at risk removed from vagina and parametria --> more relapses. I think we'll see robotic hystero losing popularity in cervical cancer. It would be better for patients.

 

[medgator]

I wonder what the rea$on could be.

No increased reimbursement to the surgeon. The hospital gets the all the financial benefit. Maybe in the employed model, the hospital is kicking back some of that robot revenue to them

 

[emt409]

What were the specific criticisms?

That MD Anderson Gyn-oncs are horribly trained and all other places Gyn-oncs are obviously better than those at the Mecca?

Pretty much -- I think I specifically heard one say in as sarcastic a tone as possible, "Mehhhhh well MD Anderson thinks we should never use the robot againnnnn"

 

[emt409]

Once again, robotic specimens appear to be smaller than ones from open radhys. Less tissue at risk removed from vagina and parametria --> more relapses. I think we'll see robotic hystero losing popularity in cervical cancer. It would be better for patients.

Not just robo, all lap....

But yeah, I think you're right, and soon someone will replicate for endometrial, and I bet the difference in relapse will be even larger.

 

[littleemma]

for those wondering the results for endometrial cancer. the outcome is equal by minimally invasive versus open surgery.

Janda M, Gebski V, Davies LC, et al. Effect of Total Laparoscopic Hysterectomy vs Total Abdominal Hysterectomy on Disease-Free Survival Among Women With Stage I Endometrial Cancer: A Randomized Clinical Trial. JAMA 2017;317:1224-33.

Fleshman J, Sargent DJ, Green E, et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 2007;246:655-62; discussion 62-4.

Walker JL, Piedmonte MR, Spirtos NM, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol 2012;30:695-700.

 

[emt409]

for those wondering the results for endometrial cancer. the outcome is equal by minimally invasive versus open surgery.

Janda M, Gebski V, Davies LC, et al. Effect of Total Laparoscopic Hysterectomy vs Total Abdominal Hysterectomy on Disease-Free Survival Among Women With Stage I Endometrial Cancer: A Randomized Clinical Trial. JAMA 2017;317:1224-33.

Fleshman J, Sargent DJ, Green E, et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 2007;246:655-62; discussion 62-4.

Walker JL, Piedmonte MR, Spirtos NM, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol 2012;30:695-700.

Thanks, that's helpful. Probably because staging discord. Stage 1B1 & 1B2 cervical higher risk for LN involvement than IB endometrial. Gyn cancer staging so stupid.

 

[evilbooyaa]

Not just robo, all lap....

Yeah the one 'valid' criticism I've seen is that majority of these were laparoscopic but not robotic (244 out of 289, from supplementary appendix, table S7) and that robotic is different. The numerical rates of DFS aren't great even with robotic, but due to smaller sample size, the robotic arm's 95% CI crosses 0. Most of the results seem to be driven by the laparoscopic patients.

 

[emt409]

Yeah the one 'valid' criticism I've seen is that majority of these were laparoscopic but not robotic (244 out of 289, from supplementary appendix, table S7) and that robotic is different. The numerical rates of DFS aren't great even with robotic, but due to smaller sample size, the robotic arm's 95% CI crosses 0. Most of the results seem to be driven by the laparoscopic patients.

I hadn't gone through supplementary materials yet....S4 is pretty interesting

The fact that the majority of failures were in the pelvis and multiple, seem to indicate to me that pelvic node undersampling and tumor spillage are the likely culprit drivers of increased recurrence risk.

I don't know enough about RA vs lap to know whether tumor spillage is different, but we know from path samples that robo doesn't get any more LN's than lap (maybe it can, but the gyn onc's just don't chase them).

 

[Reaganite]

So I have a woman in her 40s with a 3cm SCC, just under 1/3 stromal invasion, negative margins, no LVI, 5 negative pelvic nodes s/p robotic assisted "radical" hys. Would any of you consider postop radiation in light of these data?

 

[Palex80]

So I have a woman in her 40s with a 3cm SCC, just under 1/3 stromal invasion, negative margins, no LVI, 5 negative pelvic nodes s/p robotic assisted "radical" hys. Would any of you consider postop radiation in light of these data?

Haha! That's a good question. The type of surgery is not a classical risk factor and since your patient does not have any other risk factors, I wouldn't treat. But indeed in light of the data posted, one could speculate if she would benefit from adjuvant RT.

I find it a bit odd that the surgeons only recected 5 nodes, was it a sentinel procedure? That could potentially also be an issue in my opinion.

 

[seper]

I would ask pathologist to measure margin width (both paracervical and vaginal). If either of them is <=2 mm, consider them positive and radiate.
Anecdotally I notice that nodal yields are much lower since circa 2013 when surgeons switched to robotic radhys.

Haha! That's a good question. The type of surgery is not a classical risk factor and since your patient does not have any other risk factors, I wouldn't treat. But indeed in light of the data posted, one could speculate if she would benefit from adjuvant RT.

I find it a bit odd that the surgeons only recected 5 nodes, was it a sentinel procedure? That could potentially also be an issue in my opinion.

 

[evilbooyaa]

So I have a woman in her 40s with a 3cm SCC, just under 1/3 stromal invasion, negative margins, no LVI, 5 negative pelvic nodes s/p robotic assisted "radical" hys. Would any of you consider postop radiation in light of these data?

Data on radical hysterectomy is too new to suggest robotic hysterectomy is an independent prognostic factor for recurrence. I wouldn't treat, but may consider imaging a bit more frequently than usual and following for early salvage if patient fails. Her chances of failing are still ~10% so not some huge risk that you're going to improve on with adjuvant RT.

 

[emt409]

Data on radical hysterectomy is too new to suggest robotic hysterectomy is an independent prognostic factor for recurrence. I wouldn't treat, but may consider imaging a bit more frequently than usual and following for early salvage if patient fails. Her chances of failing are still ~10% so not some huge risk that you're going to improve on with adjuvant RT.

She's stage II (IIB by old staging), so she needs brachy at the very least? So, ~25% recurrence risk w/o adj RT. And if we conservatively assume same abs diff increase of "min invasive" vs open from IB1 & IB2 in NEJM study, then your patient is looking at >30% recurrence risk.

 

[evilbooyaa]

She's stage II (IIB by old staging), so she needs brachy at the very least? So, ~25% recurrence risk w/o adj RT. And if we conservatively assume same abs diff increase of "min invasive" vs open from IB1 & IB2 in NEJM study, then your patient is looking at >30% recurrence risk.

What makes her stage II? I'm reading it as 1/3 stromal invasion of the cervix. Patient doesn't meet Sedlis criteria. Use of brachy alone for adjuvant cervical cancer is not standard and I'm not aware of any studies evaluating this. Hell, use of brachy with EBRT as adjuvant treatment is not standard, as the Sedlis GOG trial evaluating EBRT didn't use brachy.

I think you may be getting this scenario confused with endometrial staging(?), where endocervical stromal involvement used to be stage II, but is no longer per most recent FIGO update.

I was reading the scenario as a cervical cancer s/p radical hysterectomy, not an endometrial cancer. An endometrial cancer wouldn't require a radical hysterectomy, robotic or not.

 

[emt409]

What makes her stage II? I'm reading it as 1/3 stromal invasion of the cervix. Patient doesn't meet Sedlis criteria. Use of brachy alone for adjuvant cervical cancer is not standard and I'm not aware of any studies evaluating this. Hell, use of brachy with EBRT as adjuvant treatment is not standard, as the Sedlis GOG trial evaluating EBRT didn't use brachy.

I think you may be getting this scenario confused with endometrial staging(?), where endocervical stromal involvement used to be stage II, but is no longer per most recent FIGO update.

I was reading the scenario as a cervical cancer s/p radical hysterectomy, not an endometrial cancer. An endometrial cancer wouldn't require a radical hysterectomy, robotic or not.

Whoops, I was def in endometrial mode. Had just gotten done putting three cylinders in for endometrial ladies yest.

 

[ramsesthenice]

An endometrial cancer wouldn't require a radical hysterectomy, robotic or not.

Unless you knew that had cervical stromal involvement. If you know they have cervical stromal involvement up front and no other indications for radiation (like nodes) and you don't do a radical you are committing them to adjuvant therapy.

 

[seper]

Interestingly, the guidelines and practice very recently changed. GynOncs no longer do radical hys (i.e. generous resection of parametria and upper vagina) for clinically apparent stage II endometrial cancer. My surgeons just do simple hys --> aggressive postop RT.
ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up. - PubMed - NCBI

Unless you knew that had cervical stromal involvement. If you know they have cervical stromal involvement up front and no other indications for radiation (like nodes) and you don't do a radical you are committing them to adjuvant therapy.