Optimal candidates for cervical conization before primary radical hysterectomy in early cervical cancer: A Korean multi-center study

Abstract

Objectives Both SUCCOR cone study and a Korean two-center matched cohort study reported a reduced risk of relapse in patients with early cervical cancer who had cervical conization prior to radical hysterectomy (RH). This study aimed to further identify a subgroup of patients who might benefit from cervical conization.

Methods From five institutions in Korea, we identified patients with node-negative, margin-negative, parametria-negative, 2009 FIGO stage IB1 cervical cancer who received primary Type C RH between 2006 and 2020. Only those with squamous cell carcinoma (SCC), usual type adenocarcinoma, or adenosquamous carcinoma were included. Patients were divided into multiple groups by the use of cervical conization, surgical approach (open vs minimally invasive surgery [MIS]), and histologic type (SCC vs non-SCC). Clinical-pathologic characteristics and survival outcomes were compared, and multivariable analysis was used to adjust confounding factors, including tumor size.

Results In total, 790 patients were included in this analysis. Compared to the control group (n = 567), the conization group (n = 223) had smaller cervical tumors and more SCCs. The conization group received MIS more often and adjuvant treatment less often. Despite no difference in overall survival, the conization group showed significantly improved disease-free survival (DFS) (3-year DFS rate, 93.4% vs 88.0%; P = 0.010), corresponding to a 49.2% reduction in the risk of relapse (adjusted hazard ratio [aHR]: 0.522, 95% CI: 0.305–0.893, P = 0.018). Such a protective effect of cervical conization on disease relapse was also observed in a subgroup of patients who received RH by minimally invasive surgery (MIS) (n = 487) (aHR: 0.507, 95% CI: 0.274–0.939, P = 0.031), but not in a subgroup of patients who received RH by open surgery (n = 303). In terms of histologic type, cervical conization significantly reduced the risk of relapse in SCC patients (n = 516) (aHR: 0.452, 95% CI: 0.230–0.889, P = 0.021) but not in non-SCC patients (n = 274). In a subgroup of SCC, patients who underwent MIS with prior conization showed similar DFS to those who underwent open surgery (P = 0.982) but showed significantly better DFS than those who underwent MIS without conization (3-year DFS rate, 93.3% vs 87.2%; P = 0.034 and aHR: 0.402, 95% CI: 0.183–0.883, P = 0.023). Consistent results were observed among patients with cervical tumors <2 cm and among those with cervical tumors 2–4 cm. However, in a subgroup of non-SCC, there was no difference in DFS between the patients who underwent MIS with or without prior conization and those who underwent open surgery (P = 0.439). During a median observation period of 57.7 months, only 4 (6.1%) of the 66 patients who did not have any cervical tumor left after conization relapsed.

Conclusions Our multicenter study results suggest patients with 2009 FIGO stage IB1 cervical cancer who have SCC histology and are scheduled to undergo primary MIS RH are subjects who might benefit from cervical conization, as conization was associated with a lower recurrence rate. Further prospective studies are warranted.