The effect of surgery on the survival status of patients with locally advanced cervical cancer after radiotherapy/chemoradiotherapy: a meta-analysis

Surgery-based radiation-free multimodality treatment for locally advanced cervical cancer

The current review described a 55-year woman using 28 months to finish her surgery-based radiation-free multimodality treatment journey to fight International Federation of Gynaecology & Obstetrics (FIGO) 2018 clinical stage IIA2 (cT2aN0M0) squamous cell carcinoma (SCC) of the cervix. She received six cycles of perioperative adjuvant therapy, including three cycles of neoadjuvant therapy (NAT) and three cycles of postoperative adjuvant therapy by using combination of dose-dense chemotherapy (CT, weekly paclitaxel 80 mg/m2+triweekly cisplatin 40 mg/m2), immunotherapy (IO, triweekly pembrolizumab 200 mg) and half-dose anti-angiogenic agent (triweekly bevacizumab 7.5 mg/kg) plus interval radical surgery (radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para-aortic lymph node sampling) and following maintenance therapy with monthly 22 cycles of half-dose of IO (pembrolizumab 100 mg) and concomitant 4 cycles of single-agent CT (paclitaxel 175 mg/m2) and 18 cycles of half-dose anti-angiogenic agent (bevacizumab 7.5 mg/kg). During the cervical SCC fighting journey, two unwanted adverse events (AEs) occurred. One was pseudo-progressive disease during the NAT treatment and pathology-confirmed upgrading FIGO stage IIIC1p (ypT2a1N1M0) after radical surgery and the other was the occurrence of hypothyroidism during the post operative adjuvant therapy. Based on this case we presented, we review the recent trend in the management of women with locally advanced cervical cancer (LACC) using the radiation-free but surgery-based multimodality strategy and highlight the strengths and limitations about perioperative adjuvant therapy with dose-dense CT + IO + half-dose anti-angiogenic agent and maintenance treatment of half-dose IO combining with short-term single agent CT and following long-term half-dose anti-angiogenic agent. All underscore the possibility that women with LACC have an opportunity to receive surgery-based RT-free multi-modality strategy to manage their diseases with satisfactory results. Additionally, the evolving role of IO plus CT with/without anti-angiogenic agent functioning as either primary treatment or adjuvant therapy for the treatment of advanced CC has been in process continuously. Moreover, the patient's positive response to IO, pembrolizumab as an example, both during the primary and maintenance therapy, highlights the importance of integrating IO into CT regimens for CC, especially in cases where conventional therapies, RT as an example, are insufficient or who do not want to receive RT-based treatment. The sustained disease-free status of the patient over several years reinforces the potential of IO to significantly increase long-term survival outcomes in CC patients, particularly for those with LACC.

Locally Advanced Cervical Cancer: Neoadjuvant Treatment versus Standard Radio-Chemotherapy-An Updated Meta-Analysis

BACKGROUND

The treatment of choice for patients with locally advanced cervical cancer (LACC) is definitive concurrent radio chemotherapy which consists of external beam radiotherapy (EBRT) and concurrent platinum-based chemotherapy (CCRT), with the possible addition of brachytherapy (BT). However, the benefits of adjuvant surgery after neoadjuvant treatments remain a debated issue and a still open question in the literature. This meta-analysis aims to provide an updated view on the controversial topic, focusing on comparing surgery after any adjuvant treatment and standard treatment.

METHODS

Following the recommendations in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, the PubMed and Embase databases were systematically searched in April 2023 for early publications. No limitations on the country were applied. Only English articles were considered. The comparative studies containing data about disease-free survival (DFS) and/or overall survival (OS) were included in the meta-analysis.

RESULTS

The CCRT + surgery group showed a significantly better DFS than CCRT (RR 0.69 [95% CI 0.58-0.81] p < 0.01) and a better OS (RR 0.70 [95% CI 0.55-0.89] p < 0.01). Nine studies comparing neoadjuvant chemotherapy (NACT) plus surgery and CCRT were also enrolled. The NACT + surgery group showed a significantly better DFS than CCRT (RR 0.66 [95% CI 0.45-0.97] p < 0.01) and a better OS (RR 0.56 [95% CI 0.38-0.83] p < 0.01). In the sub-analysis of three randomized control trials, the surgery group documented a non-significantly better DFS and OS than CCRT (OR 1.10 [95% CI 0.67-1.80] p = 0.72; I2 = 69% p = 0.72; OR 1.09 [95% CI 0.63-1.91] p = 0.75; I2 = 13% p = 0.32).

CONCLUSION

The results provide updated findings about the efficacy of neoadjuvant treatments, indicating significantly improved DFS and OS in patients undergoing hysterectomy after CCRT or NACT compared with patients undergoing standard treatments.

Nomogram for prognosis of elderly patients with cervical cancer who receive combined radiotherapy

This retrospective study identified prognostic factors to help guide the clinical treatment of elderly patients (≥ 65 years) with cervical cancer who had undergone radiotherapy. A personalized model to predict 3- and 5-years survival was developed. A review was conducted of 367 elderly women with cervical cancer (staged II-III) who had undergone radiotherapy in our hospital between January 2012 and December 2016. The Cox proportional hazards regression model was used for survival analysis that considered age, hemoglobin, squamous cell carcinoma antigen, pathologic type, stage, pelvic lymph node metastasis status, and others. A nomogram was constructed to predict the survival rates. The median follow-up time was 71 months (4-118 months). The 3- (5-) years overall, progression-free, local recurrence-free, and distant metastasis-free survival rates were, respectively, 91.0% (84.4%), 92.3% (85.9%), 99.18% (99.01%), and 99.18% (97.82%). The following were significant independent prognostic factors for overall survival: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The C-index of the line chart was 0.699 (95% CI 0.652-0.746). The areas under the receiver operating characteristic curves for 3- and 5-years survival were 0.751 and 0.724. The nomogram was in good concordance with the actual survival rates. The independent prognostic factors for overall survival in elderly patients with cervical cancer after radiotherapy were: tumor size, pre-treatment hemoglobin, chemotherapy, and pelvic lymph node metastasis. The novel prognostic nomogram based on these factors showed good concordance with the actual survival rates and can be used to guide personalized clinical treatment.

Application of sevoflurane combined with remifentanil anesthesia in laparoscopic radical hysterectomy for cervical cancer

OBJECTIVE

To explore the effects of sevoflurane combined with remifentanil anesthesia on the physical stress and immunologic function of patients undergoing laparoscopic radical hysterectomy for cervical cancer.

METHODS

The clinical data of 74 patients undergoing laparoscopic radical hysterectomy for cervical cancer were retrospectively analyzed. Patients were divided into two groups according to the different anesthesia methods, among which 37 cases received propofol and remifentanil anesthesia were set as a control group (CG), and 37 cases received sevoflurane and remifentanil anesthesia were set as an observation group (OG).

RESULTS

The OG showed a lower heart rate, Ramsay score and bispectral index than the CG 30 min after the start of the surgery and at the end of the surgery. The levels of glucagon, angiotensin II and cortisol in the OG were lower than those in the CG upon skin incision, at the end of surgery, and at 1 h after surgery (P < 0.05). The levels of CD3⁺ and CD4⁺ of the OG were higher than those of the CG at 1 d and 3 d after surgery. In terms of Montreal Cognitive Assessment and Mini-Mental State Examination scores 1 d after surgery, the OG was higher than the CG.

CONCLUSION

Sevoflurane combined with remifentanil anesthesia for patients undergoing laparoscopic radical hysterectomy for cervical cancer is superior to propofol and remifentanil, and can ensure stable hemodynamics and mitigate physical stress, so it is worthy of clinical application.

Laparoscopic Versus Abdominal Radical Hysterectomy for Cervical Cancer: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopic radical hysterectomy (LRH) and open abdominal radical hysterectomy (ARH) have been used for cervical cancer treatment. We aimed to perform a meta-analysis to compare the efficacy and safety of LRH and ARH in the treatment of cervical cancer to provide reliable evidence to the clinical cervical cancer treatment.

METHODS

Two investigators independently searched PubMed and other databases for randomized controlled trials (RCTs) comparing LRH and ARH for cervical cancer treatment up to May 31, 2022. The risk of bias assessment tool recommended by Cochrane library was used for quality assessment. RevMan 5.3 software was used for meta-analysis.

RESULTS

Fourteen RCTs with a total of 1700 patients with cervical cancer were finally included. Meta-analyses indicated that compared with ARH, LRH reduced the intraoperative blood loss (mean difference [MD]=-58.08; 95% CI, -70.91, -45.24), the time to first passage of flatus (MD=-14.50; 95% CI, -16.55, -12.44) (all P <0.05), and increase the number of lymph nodes removed (MD=3.47; 95% CI, 0.51, 6.43; P =0.02). There were no significant differences in the duration of surgery (MD=27.62; 95% CI, -6.26, 61.49), intraoperative complications (odd ratio [OR]=1.10; 95% CI, 0.17, 7.32), postoperative complications (OR=0.78; 95% CI, 0.33, 1.86), relapse rate (OR=1.45; 95% CI, 0.56, 3.74), and survival rate (OR=0.75; 95% CI, 0.52, 1.08) between LRH group and ARH group (all P >0.05).

CONCLUSIONS

LRH has more advantages over ARH in the treatment of cervical cancer. Still, the long-term effects and safety of LRH and ARH need more high-quality, large-sample RCTs to be further verified.

Successful treatment of locally advanced bulky cervical cancer complicated by irreducible complete uterine prolapse: A case report

RATIONALE

Cervical cancer complicated by irreducible complete uterine prolapse in elderly patients is extremely rare. No standard treatment has been established for these conditions.

PATIENT CONCERNS

A 74-year-old woman with a 30-year history of pelvic organ prolapse presented with irreducible complete uterine prolapse and a large exophytic mass involving the cervix and vaginal wall.

DIAGNOSIS

Biopsy of the mass was performed at the referring institution and showed invasive verrucous-type squamous cell carcinoma.

INTERVENTIONS

A prolapsed uterus with a tumor mass could not be manually reduced. After completion of concurrent chemoradiotherapy, the tumor mass in the prolapsed uterus decreased and could be reduced manually. Subsequently, the patient underwent hysterectomy and intra-abdominal uterosacral ligament suspension.

OUTCOMES

At 19 months of postoperative follow-up, the patient remained disease-free and had no evidence of vault prolapse.

LESSONS

This study has important clinical implications and may provide a therapeutic strategy to address unmet medical needs in combination with locally advanced cervical cancer complicated by irreducible complete uterine prolapse. These conditions were successfully treated using a multidisciplinary approach of chemoradiotherapy followed by radical hysterectomy and uterosacral ligament suspension.

Predictive value of hemoglobin, platelets, and D-dimer for the survival of patients with stage IA1 to IIA2 cervical cancer: a retrospective study

Objective

Coagulation indexes may be useful survival biomarkers for cervical cancer. This study evaluated the ability of hemoglobin, red blood cells (RBCs), platelets, and D-dimer levels to predict post-hysterectomy survival outcomes in patients with stage IA1 to IIA2 cervical cancer.

Methods

In this retrospective study, coagulation-related indexes were compared between the anemia and non-anemia groups. Independent variables were analyzed by the Cox proportional hazards model. Survival was assessed by the Kaplan–Meier method with the log-rank test. Mortality predictions were evaluated by receiver operating characteristic curves.

Results

Among this study’s 1088 enrolled patients, 152 had anemia. The 10-year overall survival and recurrence-free survival rates were 90.8% and 86.5%, respectively. Hemoglobin, RBC, and the rate of abnormal platelet counts were significantly lower in the anemia group. Abnormal preoperative D-dimer was an independent factor for recurrence-free survival. Receiver operating characteristic curves showed that D-dimer had area under the curve of 0.734 (cut-off value: 0.685, sensitivity: 85.7%, and specificity: 64.0%). Hemoglobin and platelets had areas under the curves of 0.487 and 0.462, respectively.

Conclusion

Preoperative D-dimer was the most effective prognostic predictor for patients with cervical cancer. The prognosis of patients with cervical cancer was poorer if their D-dimer levels were >0.685 mg/L.

Adjuvant Hysterectomy for Cervical Cancer Patients Treated with Chemoradiation Therapy: A Systematic Review on the Pathology-Proven Residual Disease Rate

Objective: To determine the incidence of pathology-proven residual disease in adjuvant hysterectomy specimens in patients with cervical cancer, treated with chemoradiation therapy. Secondly, to assess a possible association for pathology-proven residual disease regarding the time between chemoradiation therapy and adjuvant hysterectomy. Additionally, the survival rate and complication rate were assessed. Methods: PubMed, EMBASE, and the Cochrane database were searched from inception up to 8 March 2021. Results: Of the 4601 screened articles, eleven studies were included. A total of 1205 patients were treated with chemoradiation therapy and adjuvant hysterectomy, ranging from three to twelve weeks after chemoradiation therapy. A total of 411 out of 1205 patients (34%) had pathology-proven residual disease in the adjuvant hysterectomy specimen. There was no association found in the time between chemoradiation therapy and adjuvant hysterectomy. Follow-up ranged from 2.4 to 245 months, during which 270 patients (22%) relapsed, and 298 patients (27%) were deceased. A total of 202 (35%) complications were registered in 578 patients. Conclusion: there is no association found in the time between chemoradiation therapy and residual disease on adjuvant hysterectomy specimens. The survival rates after chemoradiation therapy and adjuvant hysterectomy are suboptimal, while the risk of complications after adjuvant hysterectomy is high.

Salvage surgery for patients with residual disease after chemoradiation therapy for locally advanced cervical cancer: A systematic review on indication, complications, and survival

Introduction

Standard treatment for locally advanced cervical cancer is chemoradiation therapy. Treatment with chemoradiation therapy harbors a risk of local residual disease, which can be curatively treated with salvage surgery, but the risk of complications following surgical procedures in radiated tissue is not negligible. The presence of residual disease can be radiologically and/or histologically diagnosed. The objective of this study is to describe studies that report on salvage surgery for patients with locally advanced cervical cancer after primary treatment with chemoradiation therapy. Therefore, we assessed the method of determining the presence of residual disease, the risk of complications, and the survival rate after salvage surgery.

Material and methods

PubMed, EMBASE, and the Cochrane database were searched from inception up to 6 March 2020. Titles and abstracts were independently assessed by two researchers. Studies were eligible for inclusion when patients had locally advanced cervical cancer with radiologically suspected or histologically confirmed residual disease after chemoradiation therapy, diagnosed with a CT, MRI, or PET‐CT scan, or biopsy. Information on complications after salvage surgery and survival outcomes had to be reported. Methodological quality of the articles was independently assessed by two researchers with the Newcastle‐Ottawa scale.

Results

Of the 2963 screened articles, six studies were included, representing 220 women. A total of 175 patients were treated with salvage surgery, of whom 27%‐100% had residual disease on the surgery specimen. Of the 161 patients treated with salvage surgery based on positive biopsy results, 72%‐100% showed residual disease on the surgery specimen. Of the 44 patients treated with salvage surgery based on suspected residual disease on radiology, 27%‐48% showed residual disease on the salvage surgery specimen. A total of 105 complications were registered in 175 patients treated with salvage surgery. The overall survival rate after salvage surgery was 69% (mean follow‐up period of 24.9 months).

Conclusions

It is necessary to confirm residual disease by biopsy before performing salvage surgery in patients with locally advanced cervical cancer primarily treated with chemoradiation therapy. Salvage surgery only based on radiologically suspected residual disease should be avoided to prevent unnecessary surgery and complications.

Chemoradiotherapy alone vs. chemoradiotherapy and hysterectomy for locally advanced cervical cancer: A systematic review and updated meta-analysis

The benefit of adjuvant hysterectomy after definitive concurrent chemoradiotherapy (CCRT) for locally-advanced cervical cancer (LACC) is controversial. The purpose of the present study was to systematically search the literature and perform a meta-analysis to compare overall survival (OS) and disease-free survival (DFS) between patients subjected to CCRT with hysterectomy and those who underwent CCRT alone. The PubMed, Scopus, Embase and Google scholar databases were searched. A meta-analysis to determine hazard ratios (HRs) and odds ratios (ORs) with meta-regression was performed for the following moderators: Disease stage, histology and proportion of radical hysterectomy. Data from 14 studies were included. The results indicated that patients who received CCRT with hysterectomy had significantly better OS (HR, 0.72; 95% CI, 0.56 to 0.91; I²=19%; P=0.007) and DFS (HR, 0.72; 95% CI, 0.56 to 0.93; I²=27%; P=0.01) than those treated with CCRT alone. However, in a subgroup analysis by study type, the results were significant only for retrospective studies but not for randomized controlled trials (RCTs). However, only 2 RCTs were included with small sample size, heterogeneity and low overall quality. Subgroup analyses based on the use of brachytherapy in the CCRT with hysterectomy group demonstrated no difference in OS and DFS between the two groups. Regarding the absolute numbers of death and recurrence events, no significant difference in mortality (OR, 0.91; 95% CI, 0.62 to 1.33; I²=0%; P=0.64) was determined between the two groups, but a significantly reduced incidence of recurrence was observed in the CCRT with hysterectomy group (OR, 0.61; 95% CI, 0.47-0.79; I²=29%; P=0.0002). The meta-regression results point to a significant influence of the proportion of stage II patients on OS. Despite the overall analysis indicating improved OS and DFS with the use of adjuvant hysterectomy after CCRT, subgroup analysis based on similar treatment protocols failed to demonstrate any significant benefit of hysterectomy in LACC. However, the results indicated that the recurrence rate may be higher in patients undergoing CCRT without hysterectomy. The limited quality of the studies included and selection bias from retrospective studies restrict the possibility to draw strong conclusions.

Post-radiotherapy hysterectomy does not benefit females with cervical adenocarcinoma

Cervical adenocarcinoma is associated with a poor prognosis, which may be caused by the infiltrative growth pattern and metastasis of tumor cells. There is a lack of consensus on hysterectomy after radiotherapy for the improvement of selected cases. The present study aimed to assess the oncological outcome of post-radiotherapy hysterectomy in females with cervical adenocarcinoma. A total of 39 females with cervical adenocarcinoma at stages IB1 to IIIB, managed primarily with radiotherapy with complete response, and underwent extrafascial hysterectomy as consolidation therapy between 1988 to 2015 were studied. Surgery complications and residual disease were evaluated. A comparison group was constructed, comprising 41 females with cervical adenocarcinoma managed with exclusive radiotherapy or chemoradiotherapy demonstrating complete response, without surgery. Descriptive and survival analysis was performed. The groups were comparable in terms of age, cancer stage, radiotherapy (dose and duration) and follow-up, although 67% of hysterectomies were performed prior to 2002 and 46% of the radiotherapy group received chemoradiation. Late complications were similar. There were nine recurrences (23%) in the case series and 10 recurrences (24%) in the radiotherapy group. Residual disease was detected in 56% (22/39) of uterine specimens, of which 12 were up to 10 mm. Residual disease was associated with recurrence (31% vs. 6%, P=0.028). The overall survival rate was 75% for the case series vs. 88% for the radiotherapy group (P=0.579), and the disease-free survival rate was 79-80% for both. Removal of residual disease by hysterectomy did not improve the overall survival rate (P=0.283) and disease-free survival rate (P=0.072). Post-radiotherapy hysterectomy in cervical adenocarcinoma is a feasible procedure with acceptable complications, however, it did not bring relevant benefits in recurrences, disease-free survival, and overall survival rates.

LINC02535 co-functions with PCBP2 to regulate DNA damage repair in cervical cancer by stabilizing RRM1 mRNA

Cervical cancer (CC) is one of the commonest malignant cancers among women with high morbidity and mortality. Despite encouraging advances had been found in diagnostic and therapeutic strategies, effective therapeutic strategy and further exploration of the mechanism underlying in CC is still needed. We searched The Cancer Genome Atlas database and found that long noncoding RNA LINC02535 was highly expressed in CC. LINC02535 has not been studied in CC, and its molecular regulation mechanism remains unknown. Based on starBase database, LINC02535 could potentially bind poly (rC) binding protein 2 (PCBP2). In the present study, we discovered a significant increase of the LINC02535 and PCBP2 expression in CC tissues and cells as compared with the adjacent normal tissues and normal cervical epithelial cells. LINC02535 and PCBP2 can bind with each other and were colocated in cytoplasm. LINC02535 and PCBP2 promoted cell proliferation, migration, invasion, and suppressed apoptosis in CC. LINC02535 and PCBP2 facilitated the repair of DNA damage to promote CC progression. LINC02535 cooperated with PCBP2 to enhance the stability of RRM1 messenger RNA (mRNA). RRM1 promoted the repair of DNA damage and epithelial-to-mesenchymal transition (EMT) process in CC cells. LINC02535 regulated tumorigenesis in vivo. In conclusion, LINC02535 cooperated with PCBP2, regulated stability of RRM1 mRNA to promote cell proliferation and EMT process in CC cells by facilitating the repair of DNA damage, providing a potential biomarker for CC.

Designing Dihydrofolate Reductase Inhibitors as X-ray Radiosensitizers to Reverse Radioresistance of Cervical Cancer

X-ray radiotherapy has been widely used in the treatment of cervical cancer, a common gynecologic malignant tumor. However, the therapeutic efficacy tends to be indistinctive. One major reason for this is amplification of the dihydrofolate reductase (DHFR) gene, which causes an increase in DHFR activity and attenuation of the treatment effect. To solve this problem, we synthesized a series of DHFR inhibitors derived from methotrexate (MTX) analogues as radiotherapy sensitizers. Activity screening revealed that compound 2a exerted the best inhibitory effect toward DHFR activity. In combination with X-ray radiotherapy (4 Gy), 2a showed much more prominent antiproliferative activity on cervical cancer cells than 2a or X-rays alone and revealed higher selectivity and radiosensitization than MTX. In vitro experiments showed that 2a + X-rays significantly induced cell apoptosis, as revealed by the increase in the Sub-G1 population and activation of caspase 3, 8, and 9. The in vivo antitumor effect demonstrated that in the presence of X-rays, 2a effectively suppressed tumor growth and did not cause obvious side effects. In conclusion, as a DHFR inhibitor, 2a successfully reversed the radioresistance problem induced by radiotherapy and greatly promoted the therapeutic effect. This is a promising candidate for tumor treatment that deserves further research and development. This study clearly demonstrates that DHFR inhibitors could be developed as promising radiosensitizers in the treatment of cervical cancer and that further research to improve their activity and potential in future clinical use is deserved.

Effect of radiotherapy on the survival of cervical cancer patients: An analysis based on SEER database

Cervical cancer is among the most frequent cancer types in women worldwide. Radiotherapy, including external beam radiation and brachytherapy, is one of the commonly used treatment options for cervical cancer. However, the adverse effects of radiation therapy on cervical cancer survival have been poorly investigated with inconclusive results. Therefore, the aim of this study was to determine the suitable radiotherapy modality according to patients' characteristics. A retrospective survival analysis of 44,602 patients was performed using the Surveillance, Epidemiology, and End Results (SEER) database. Multivariate proportional hazard Cox model was used to evaluate the prognostic impact of different radiotherapy modalities, primary surgery, age, TNM stage, and tumor size. Our results indicated that patients without primary surgery, diagnosed at older age (≥45 years' old), at advanced TNM stages (III/IV) or with larger tumor size (≥3 cm) could benefit from radiotherapy. However, radiotherapy was detrimental in patients with primary surgery, diagnosed at younger age (<45 years' old), at earlier TNM stages (I/II) or with smaller tumor size (<3 cm). In addition, external beam radiation was in most cases less effective compared with combined external beam and brachytherapy. These results highlighted the necessity of realizing personalized radiotherapy treatments for patients with cervical cancer.

Is adjuvant hysterectomy an option after radio-chemotherapy for locally advanced cervical cancer? A review

Objective. The purpose of this paper is to review the current concepts in the literature regarding the beneficial effects of adjuvant surgery after concurrent radio-chemotherapy for locally advanced cervical cancer. Method. Research of the literature was performed using PubMed databases in order to find articles relevant to the central topic. The PICOS criteria were used to filter the results. The paper was then structured according to the PRISMA guideline. Results. 50 individual papers were analyzed and sorted according to their relevance for the topic. 18 were classified as relevant. There was little agreement as to how beneficial adjuvant hysterectomy is in locally advanced cervical cancer after chemoradiotherapy. Some articles concluded that patients with a total clinical response after initial treatment might have superior progression-free survival and overall survival after surgery. 2 articles underlined the importance of accurate restaging after primary treatment. The lack of benefit for surgery in patients with bulky disease or persistent adenopathies was agreed upon in all cases. Conclusions. The decision for adjuvant hysterectomy with or without lymphadenectomy is a controversial one and has to be personalized and taken in a multidisciplinary team.