4.Discussion
The results of a multicenter and retrospective study showed that there
were no high-risk and high-risk pathological factors in Four C. There
was no significant difference in 5-year OS between the laparotomy group
and the laparoscopy group, but the 5-year DFS in the laparotomy group
was higher than that in the laparoscopy group; Cox multivariate analysis
showed that laparoscopic surgery was an independent risk factor for
recurrence / death in patients with early cervical squamous cell
carcinoma without high and medium risk factors. In order to further
reduce bias and confounding factors, 1:2PMS was carried out and the same
conclusion was reached.
The results of this study found that there was no difference in 5-year
OS between open surgery and laparoscopic surgery, which was different
from the LACC study of Ramirez et al[1], which
believed that laparoscopic surgery was 4.5% for patients with stage
IA1(LVSI+)~IB1 cervical cancer the 5-year OS was lower
than that in the laparotomy group (86.0% vs. 96.5%). Considering the
different stages of cervical cancer included, there were about 91.5% in
the LACC study of Ramirez et al 9% of cervical cancer patients are in
stage IB1. The stage included in this study also includes stage IIA1
cervical cancer cases. The survival analysis before and after matching
in Uppal et al. [15] research showed that there
was no difference in the overall survival rate of patients with stage
IA1(LVSI+)~IB1 cervical cancer undergoing laparoscopic
surgery and laparotomy.
In terms of DFS, it is consistent with the results of LACC. It is found
that the DFS of laparoscopic surgery is lower than that of laparotomy
surgery. Cox multivariate analysis suggests that laparoscopic surgery is
an independent risk factor for recurrence / death of cervical cancer
patients. Chenx et al. [16] found that there was
no difference between the 5-year OS of laparoscopic surgery and
laparotomy surgery for cervical cancer patients with stage IB1 in FIGO
2009, but the 5-year DFS was significantly lower than that of laparotomy
group. Cox multivariate analysis showed that laparoscopic surgery was
associated with lower tumor-free survival rate, which was consistent
with the results of this research, but the study did not conduct
postoperative pathological review of surgical specimens and the sample
size was limited, This may cause selection bias and confounding factors.
Different from the results of this study, Ratiud et al.[17] analyzed the cervical cancer patients who
underwent laparotomy surgery or laparoscopic surgery in figo2009 stage
IA1 ~ IIB and found that there was no significant
difference in 5-year OS between the laparoscopic group and the
laparotomy group (94.1% vs 85.4% P = 0.311), but found that the 5-year
DFS in the laparoscopic group was higher than that in the
laparotomy group (94.1% vs 75.6% P
= 0.049), It is considered that minimally invasive surgery for patients
with stage IA1 ~ IIB cervical cancer can improve the
tumor-free survival rate. This is different from the results of this
study. The reasons are as follows: first, this study does not strictly
limit the presence or absence of adjuvant therapy and the number of
times before operation. Second: the difference between the two groups
was statistically significant in terms of baseline lymphatic vascular
infiltration. However, due to the small number of cases included in the
study, a total of 75 cases were not controlled by PSM. Third: the
histological types of the study are different. In addition to squamous
cell carcinoma, the study also includes adenocarcinoma and adenosquamous
cell carcinoma. Fourth: the study stage is figo2009 stage IA1
~ IIB, which is not specifically for early cervical
cancer cases.
At present, the conclusions of oncological prognosis of laparotomy and
laparoscopy are different in patients with different histological types
of cervical cancer. Kimsi [18] found that when the
histological type is cervical squamous cell carcinoma, the 5-year PFS of
laparoscopic surgery is lower than that of laparotomy surgery, but there
is no difference between the two groups in non cervical squamous cell
carcinoma, while other studies found no difference in oncological
outcomes between the two subtypes [6-8,19]. Leeyy[10] included 775 cases of stage IB
~ IIA cervical cancer in FIGO2009, including 636 cases
of squamous cell carcinoma and 139 cases of adenocarcinoma. The results
showed that compared with squamous cell carcinoma, adenocarcinoma before
and after matching was associated with worse survival outcome and higher
distant recurrence rate. Mabuchis et al. [20]found that the prognosis of cervical adenocarcinoma is worse than that
of cervical squamous cell carcinoma when there are any high and medium
risk pathological factors. When the histological type is adenocarcinoma,
it may affect the oncological outcome of laparotomy surgery and
laparoscopic surgery. In order to make this study more convincing, the
histological type is limited to cervical squamous cell carcinoma, and
whether the postoperative adjuvant treatment is standardized due to
high-risk pathological factors will lead to the difference of
oncological outcome between the two groups. Therefore, this study limits
the pathological factors and carries out PSM to control the confounding
factors, The results before and after matching showed that laparoscopic
surgery had worse oncological outcomes.
Patients with cervical cancer undergoing laparoscopic surgery have a
high recurrence rate, which may be related to the failure to strictly
implement the tumor free principle during the operation, the promotion
of inflammation and tumor metastasis by CO2 pneumoperitoneum during the
operation, the use of uterine lifting device during the operation, the
gasification of electrical equipment, the way of vaginal disconnection
and suture [21-24]. Vaginal uterine lifter is
related to direct contact with tumor lesions and long-term compression,
resulting in rupture of tumor cells and artificial diffusion of tumor
cells.
This study has some limitations. Firstly, the case data of 47 hospitals
in China are included in this study, which will lack some clinical data.
Secondly, there are some deviations in the surgical level and experience
of surgeons. Third, the time span of case inclusion is long, and the
surgeon’s learning curve should also be one of the factors to be
considered. Although there are some defects in our study, based on the
multi center large sample study, it can effectively reflect the
practical value of figo2018 new stage in the diagnosis and treatment of
cervical cancer in China. PSM is used to strictly control the
confounding factors. At the same time, the included pathological factors
are postoperative pathology, which is more accurate. Therefore, we
believe that the results of this study have high reliability. This study
is also a more detailed supplement to the results of previous
laparoscopic and open studies, and also provides evidence support for
the recommended laparoscopic surgical approach in NCCN guidelines.
In conclusion, for patients with FIGO2018 new stage early cervical
squamous cell carcinoma with any high-risk pathological factors, there
was no significant difference between 5-year OS of laparotomy surgery
and laparoscopic surgery. 5-year DFS of laparoscopic surgery was lower
than that of laparotomy surgery. Laparoscopic surgery was an independent
risk factor for recurrence / death of patients with cervical cancer.