Appraisal the significance of completion hysterectomy after definitive concurrent chemoradiotherapy for patients with locally advanced cervical adenocarcinoma: the ATTRACT study

Objective: To appraise if the completion hysterectomy after concurrent chemoradiotherapy (CCRT) would improve the survival outcomes for patients with locally advanced cervical adenocarcinoma (LACA). Methods: This study was conducted based on a large cohort including more than 200 LACA patients from Peking Union Medical College Hospital (PUMCH). The included patients were divided into CCRT alone and CCRT + surgery group, where overall survival (OS), progression free survival (PFS), loco-regional free survival (LRFS) and distant metastasis free survival (DMFS) were compared between two groups before and after propensity scoring matching (PSM). Cox regression analysis was performed in CCRT alone group to identify the risk factors impairing the survival probability. The survival outcomes were further compared between CCRT alone and CCRT + surgery group in different risk subgroups identified from cox regression analysis. Results: CCRT + surgery was observed to outperform CCRT alone in OS, PFS, LRFS and DMFS before PSM (All P <0.05), while the benefit of surgery couldn’t be maintained after PSM except for DMFS (3-yr DMFS: 76.8% vs 60.2%, P = 0.035). Uterus involvement (UI) was identified as the only risk factor for CCRT alone group. Surgery was found to increase the survival probability for patients with UI (All P <0.05), while it didn’t bring additional survival benefit for patients without UI (All P >0.05). In CCRT + surgery group, patients with pathological residual disease (RD) ≥ 1/2 myometrial infiltration (MI) had significant decreased survival compared to patients with RD<1/2MI or patients without RD (All P <0.05). Furthermore, post-operative chemotherapy didn’t improve survival outcomes in patients with RD<1/2MI, while it seemed to bring additional benefit for patients with RD≥1/2MI in terms of PFS with marginally significance ( P = 0.055). Conclusion: Completion hysterectomy after CCRT could increase DMFS for LACA patients, while not every LACA patients would retain OS benefit from surgery except for those with positive UI. Survival differences existed in different degree of RD among patients receiving post-radiation surgery and post-operative chemotherapy demonstrated a trend toward PFS benefit for patients with RD≥1/2MI.