1. Clinical Fellow Gynaeoncology Musgrove Park Hospital, Taunton
Regional Outcomes for Surgical Management of Early Stage Cervical Cancer
Dr S Coleridge
Clinical Fellow Gynaeoncology
Musgrove Park Hospital, Taunton
ST6 OOPR

2. Women want to know why we are recommending a particular treatment
LACC data presented
Consensus to inform women about to undergo a radical hysterectomy of unpublished trial findings
Informed consent
Montgomery ruling
Women want to know why we are recommending a particular treatment
Can provide local data to help inform shared decision making
SGO, New Orleans March
IGCS, Japan August

3. Randomised Controlled Trial Vs Retrospective Cohort
Randomly assign participants to control group (open surgery) or intervention group (minimal access surgery)
Gold standard of evidence based medicine
Minimise bias
Control for confounding factors
Observational
Middle of the hierarchy of evidence
Useful to inform clinical practice

4. Laparoscopic radical hysterectomy
Started in 1990s

5. Decreased treatment related morbidity (8%) Shorter hospital stay
LACC Hypothesis
Minimal access surgery is cost effective, improves QoL and pelvic floor function with equivalent overall survival to open surgery
Decreased treatment related morbidity (8%)
Shorter hospital stay
Less post op pain
Reduced analgesic consumption
Equivalence measured by disease free survival(DFS) within 7.2% of open DFS rate

6. Laparoscopic Radical Hysterectomy
“I'm 5 weeks post op now and feel great. I'm starting back to work next week. My incision sites are still a little sore”
“I wanted to say that I felt keyhole surgery was right option for me as the recovery time is quicker and this was important for me as a single parent of 3 kids and limited family support”

7. Open Abdominal Hysterectomy
“It's taken 4 months to start to feel ok-ish” “I'd say for anyone having the abdominal surgery....this is a hard recovery but it does get better, from speaking to people having had this op it does take a couple of months more than keyhole to get to the milestones they give you. Take it steady!”

8. Inclusion criteria
FIGO stage
1a1 with LVSI
1a2
1b1
Histological subtype
Adenocarcinoma
Squamous cell carcinoma
Adenosquamous carcinoma
Tumour size < 4cm

9. Exclusions Bristol Devon Gloucestershire Somerset Cases 51 57 42 64
Excluded 9 8 7
Total Included 49 35
Included Timeframe

10. Baseline Data SWAGGER Open Lap LACC Age (Mean) 43 44 46 46.1 Total
SWAGGER
Open
Lap
LACC
Age
(Mean)
 43
44  46
46.1
Total
in group
 30
152
312
(274)
319
(289)
1a2 3% 1
1.3% 2  6% 20 7% 21
1b1
96%
29 
92%
140 
287
293
1b2
N/A 10
6 simple TLH (2 of which on SHAPE trial)

11. Post operative Histopathology
SWAGGER
Open
Lap
LACC
Adenocarcinoma
 30% 9
39% 60
21% 58
27%
87 
Squamous
Cell
Carcinoma
67%
20 
53%
 80
50%
146
214
Adenosquamous carcinoma
 N/A
 6% 4% 12 3% 9 
<2cm
60%
18 
56%
85 
32% 89
33% 95
>2cm
 28% 42
36%
101
97 

12. Post operative Histopathology contd
SWAGGER
Open
Lap
LACC
Differentiation
Well
Moderate
Poor
Unknown
16%
50%
10%
13%  9%
35%
14%
21% 
40%
22%
28%
11%
21%
LVSI
Negative
Positive
53%
37%
10% 
55%
27%
18%
66%
29% 5%
67%
24%
Parametria
80% 3%
13%
70% 6%
25% 
89% 4% 7%
87%
Vaginal Margins
57%
40% 
65% 2%
33% 
88%

13. Post op chemoradiotherapy
LACC criteria - LVSI / tumour size / stromal invasion

14. Surgery Vs. Chemoradiotherapy
“I went on to have chemo-rads anyway and have been cancer- free ever since, but it is my firm belief that the outcome would have been the same without the unnecessary loss of body parts. …………But in all honesty, I could have done without losing the top 50% of my vagina”

15. Post operative Histopathology contd
SWAGGER
Open
Lap
LACC
Median Nodes
14 
17  21 20
Positive Nodes
3% 
 10%
 13%
12% 
Negative Nodes
 97%
 90%
86%
87%
Post op CRT
6% 
12.5% 
 28%
29% 

16. Intra operative complications
SWAGGER
Open
Lap
LACC
Any Complication* 3% 6%
10%
12%
Bladder Injury
 0%
 1%
Ureteric injury 1% 2%
Bowel Injury
  0% 0%
Blood transfusion*   
 2% 5%
Uterus rupture
Vascular Injury
Nerve injury*
Uterus rupture is not perforation
Significant difference in any complication, blood transfusion and nerve injury

17. Post operative complications
SWAGGER
Open
Lap
LACC
Wound Complication* 0% 2%
6.2%
1.4%
Vaginal Vault
Complication*
 2%
0.8%
3.9%
Lymphocele formation 1%
1.2%
Lymphoedema
 10%
 8%
0.4%
Neuropathy
 3%
2.5%
VTE 3%
Urinary Complications
14%
17.9%
22.6%
Cardiac complication*
 0%
0.7%

18. Site of first recurrence
SWAGGER
Open
Lap
LACC
Total Recurrences 3
10% 10
6.6% 7
2.2% 24
7.5%
Vault  1
33%  5
50% 3 
43% 4 
17%
Pelvis 2
66% 
20% 0  0% 7 
29%
Abdomen
0%   0 4%
Distant
14%
8% 
Multiple
Other 1
13%

19. SWAGGER progression free survival

20. LACC Progression free survival

21. Deaths due to cervical cancer Deaths due to other disease
Cause of death
SWAGGER
Open
Lap
LACC
Total Deaths 2 5 3 19
Deaths due to cervical cancer  1 3% 4   2 1%
 14 4%
Deaths due to other disease
0.7%  0 0%  4
Unknown
N/A 

22. SWAGGER Overall Survival Cancer Specific
1 death from disease open group 15y after surgery
3 deaths from disease lap group

23. LACC OVERALL Survival

24. Going Forward
What Next?

25. Thank You Mr Milliken Miss Morrison Miss Newton Mr Rolland
Mr Hannemann