The morbidity and mortality associated with surgery for Radical Hysterectomy and Pelvic Lymph Node Dissection done at Charlotte Maxeke Johannesburg Academic Hospital for cervical cancer

Abstract

Background Cancer of the cervix was ranked fourth in 2018 worldwide for both incidence (6%) and mortality (7.5%), with 570 000 estimated new cases and 311 000 deaths.1 In South Africa following breast cancer, it is the second most commonly diagnosed cancer among women. Its incidence rate increases with increasing age and was found to be 20.42 and 82.02 per 100 000 among women of ages 30-34 and 65-69 years respectively.1 It is the leading cancer among black South African women and the fifth common cancer among South African white women, and it is estimated to kill approximately 8 women every day in South Africa.64 However, early cervical cancer (IA-IB2) has a relatively favourable prognosis, with a greater than 80% survival rate.2 For early stage disease, treatment with either radical surgery or radiation appears equally effective, with 5-year survival rates of approximately 70-80%. However, radiation therapy as primary treatment for early-stage cervical cancer is usually reserved for women who are not candidates for surgery due to medical comorbidities or poor functional status. 2

Surgical approach remains the main curative intent treatment for solid tumors. Its benefit includes better access and visualisation of tumor, and the opportunity to surgically remove any grossly positive lymph nodes while maintaining the functioning of the ovaries.3 The extensive parametrectomy involved with this procedure has been associated with pelvic organs dysfunction. The main advancement in the surgical treatment of early cervical cancer has been the de-escalation of radical surgical approach, with less parametrectomy in tumors ≤ 2cm, however maintaining same oncologic outcomes.49,71

Today, the proficient performance of the RH is the bench-mark of the gynaecologic oncology surgeon. The management of early-stage disease (IA1-IB2) at the CMJAH one of the tertiary hospitals in Johannesburg South Africa, is similar to the international guidelines. However, patients with stage IIA are managed as late-stage disease with chemo-radiation.28 There exist a lot of controversies on the outcome of RH whether performed by open, laparoscopic, or robotic methods regarding the surgical outcome and histological subtypes. No available documented data exists in CMJAH, on the outcomes of cervical cancer patients treated with this procedure. This study describes the morbidity and mortality associated with RH and PLND performed on early-stage cervical cancer patients at CMJAH.

Methods and Materials We retrospectively reviewed medical records of women who underwent Radical Hysterectomy and Pelvic Lymph Node Dissection (RH and PLND) for early-stage cervical cancer at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from 1 January 2015 to 31 December 2016. Descriptive analysis of data was performed, including means and standard deviations (SD) for normally distributed data and medians and interquartile ranges (IQR) for nonnormally distributed continuous data.

The crude and unadjusted intraoperative and post-operative complications of surgery rates were calculated. Chi squared test was used to assess the relationships between groups of radical hysterectomy subtypes, demographic and clinical characteristics, staging, morphological appearance of tumors, and other histological subtypes. Fisher’s exact test was used where the requirements for the Chi squared test were not met.

Results Twenty-three women met the study criteria, eighteen blacks and five whites with a mean age of 45.65years (SD±13.23). Twenty-Three Radical Hysterectomy and Pelvic Lymph Node Dissection (RH and PLND) were performed to completion, twelve were done by a gynaecology oncologist and eleven by a training fellow gynaecologist in the unit. The commonest type of procedure performed was Q-M class B (82.61%) with level II lymph node dissection done in 52.17% of the cases. RH and PLND was performed in 86.96% (20/23) of patients with stage 1B1 disease, 8.70% (2/23) 1A2, and 4.35% (1/23) HGSIL. The histological subtypes before surgery, were Squamous cell carcinoma (69.57%), Adeno-carcinoma (17.39%), and AdenoSquamous carcinoma (13.04%).

Lymph node involvement was found in 67.00% (4/6) patients with stage IB1, 17.00% (1/6) IB2 with a basaloid variant of squamous cell carcinoma and one patient (17.00%) with advanced disease IIA2, and 5 of 6 patients received adjuvant chemo-radiation treatment, one patient with stage IB2 did not receive chemo-radiation as she got lost to follow up. The overall complications rate was 21.74% (5/23), these included post-operative ileus (8.70%), blood vessel injury (4.35%), post-operative wound infection (4.35%), and pulmonary embolism (4.35%). Pre-operative use of broad-spectrum antibiotics (cefazolin or augmentin®) was associated with lower rates of post-operative infections (4.35%) requiring admission and the use of intravenous antibiotics. Prophylactic use of low molecular weight heparin (clexane®) at a dose of 1milligram per kilogram daily was associated with 95.65% prevention of venous thromboembolic disease. No patient in our study required admission to the intensive care unit. There were no deaths reported during the study period.

Conclusion For early-stage disease, treatment with either radical surgery or radiation appears equally effective, with 5-year survival rates of approximately 70-80%. However, radiation therapy as primary treatment for early-stage cervical cancer is usually reserved for women who are not candidates for surgery due to medical comorbidities or poor functional status. Pelvic radiation therapy (with or without chemotherapy) uniformly results in ovarian failure due to the doses required for curative-intent therapy and if ovarian preservation is necessary, consideration of transposition out of the radiation field should be considered.

Open Radical Hysterectomy and Pelvic Lymph Node Dissection remains the treatment of choice for early cervical cancer, with a favourable prognosis and oncological outcomes. We have shown that when done under standardized practices, Radical Hysterectomy was associated with less morbidity and yielded lower rates of early and late complications (21.4%) with favourable oncological outcomes. The shorter turnaround time between diagnosis of disease and surgery has resulted in early intervention, before disease progression. However, more prospective studies are needed to establish this association.

The retrospective nature of our study failed to show any association between some risk factors (eg BMI) known to affect surgical outcomes as they were not recorded. Our study was limited as it had a low number of participants and did not look at other known complications of RH like sexual and lower urinary tract dysfunction. A well-structured and powered, multicentre prospective study is needed to look at the broader picture regarding the morbidity and mortality associated with RH and PLND performed for early cervical cancer.