One of the most common gynecologic neoplasms in women worldwide is cervical carcinoma. Management strategies for early-stage disease have shifted in recent years to less-radical methods in patients who are low-risk. Recent evidence has shown that simple hysterectomy with lymph node assessment can have similar outcomes to radical hysterectomy in these patients. Management for women who are diagnosed or locally upstaged after a simple hysterectomy alone is lacking in evidence; these patients are outside the scope of trials focusing on de-escalation strategies due to a lack of oncologic surgical intent and confirmation of low-risk status. This study was designed to evaluate overall survival in patients with tumors 2 cm or less who had inadvertent surgery compared to patients who underwent planned oncologic surgery with lymph node assessment. This was a retrospective cohort study using data from the National Cancer Database (NCDB). Inclusion criteria were patients with pathologically confirmed invasive cervical squamous cell carcinoma, adenosquamous carcinoma, or adenocarcinoma between January of 2010 and December of 2020, tumors 2 cm or less, and primary treatment of either simple or radical hysterectomy. Exclusion criteria were clinically or pathologically confirmed metastatic disease, parametrial invasion, history of prior synchronous malignancy, stage IA disease without lymphovascular space invasion (LVSI), and unknown LVSI status. The comparison for this study was a simple hysterectomy without lymph node assessment compared to a radical hysterectomy or a simple hysterectomy with lymph node assessment. The primary outcome was overall survival. The final analysis included 5608 patients, with 688 in the inadvertent surgery group and 4920 in the oncologic surgery group. Patients in the inadvertent surgery group were more likely to be older, have smaller tumors, greater comorbidity index scores, presentation with squamous cell histology and low-grade tumors, and receive minimally invasive surgery (MIS) . The median follow-up time was 64.6 months in the oncologic surgery group and 58.5 months in the inadvertent surgery group ( P <0.001). Five-year overall survival was 91.5% (95% CI: 87.8%-94.2%) in the inadvertent surgery group and 96.2% (95% CI: 95.5%-96.7%) in the oncologic surgery group ( P <0.001). At 10 years, overall survival was 85.2% and 90.4%, respectively (95% CI: 79.2%-89.6%, 89.0%-91.7%, respectively; P =0.002). Time-to-event analysis also showed an increased risk of mortality in the inadvertent surgery group hazard ratio (HR): 1.89, 95% CI: 1.42-2.52, P <0.001. When examining adjuvant treatment, 151 of 688 patients in the inadvertent surgery group received adjuvant treatment, and those who did were more likely to be older and present with adenocarcinoma or adenosquamous histology, high-grade tumors, and positive LVSI. There were no significant differences between patients who received adjuvant treatment and those who did not. These results indicate that inadvertent surgery is associated with decreased overall survival and that adjuvant therapy did not mitigate this effect. The implication of this is that prognosis in early-stage cervical cancer depends heavily on surgical oncologic intent and quality, as well as on other factors. This is consistent with previous de-escalation trials showing the efficacy of simple hysterectomy with oncologic intent, and with previous research of simple hysterectomy without oncologic intent for early-stage cervical cancer without a focus on tumor size. Future studies should focus on determining the underlying causes of inadvertent surgery and strategies for prevention, as well as strengthening surgical quality control, preoperative planning, and multidisciplinary case discussions. (Summarized from Agusti N, Viveros-Carreño D, Wu C-F, et al. Survival outcomes after inadvertent surgery in low-risk early-stage cervical cancer. Am J Obstet Gynecol 2026 Feb 16:S0002-9378(26)00081-5. doi: 10.1016/j.ajog.2026.02.017).
Lam Le (Mon,) studied this question.