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

OBJECTIVE: To appraise whether 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. The included patients were divided into the CCRT alone and CCRT + surgery groups, where overall survival (OS), progression-free survival (PFS), loco-regional-free survival (LRFS), and distant metastasis-free survival (DMFS) were compared between the two groups before and after propensity scoring matching (PSM). Cox regression analysis was performed in the CCRT alone group to identify the risk factors impairing the survival probability. The survival outcomes were further compared between the CCRT alone and the 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 could not be maintained after PSM except for DMFS (3-year DMFS: 76.8 vs. 60.2%, P = 0.035). Uterus involvement (UI) was identified as the only risk factor for the CCRT alone group. Surgery was found to increase the survival probability for patients with UI (all P < 0.05), while it did not bring additional survival benefit for patients without UI (all P > 0.05). In the CCRT + surgery group, patients with pathological residual disease (RD) ≥ 1/2 myometrial infiltration (MI) had significantly decreased survival compared to patients with RD<1/2MI or patients without RD (all P < 0.05). Furthermore, postoperative 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 marginal significance ( P = 0.055). CONCLUSION: Completion hysterectomy after CCRT could increase DMFS for LACA patients, while not every LACA patient would retain OS benefit from surgery, except for those with positive UI. Survival differences existed in different degrees of RD among patients receiving post-radiation surgery and postoperative chemotherapy, demonstrating a trend toward PFS benefit for patients with RD≥1/2MI.