1 Less Radical Surgery for Patients with Early-Stage Cervical Cancer Dr.Yousefi Professor Mashhad University of Medical Sciences

1www.zohrehyousefi.com

Less Radical Surgery for Patients with Early-Stage

Cervical Cancer

Dr.Yousefi Professor Mashhad University of Medical Sciences

Gynecologist Oncologist


Ovarian Transposition

Extent of Hysterectomy

lymph node metastasis

Sentinel node mapping

radical trachelectomy


Ovaries are detached from the uterus along with itsOvaries are detached from the uterus along with its

blood supply and transposed in an area away from theblood supply and transposed in an area away from the

radiation field, generally in the para-colic gutters radiation field, generally in the para-colic gutters

abovethe pelvic brim.abovethe pelvic brim.

Drawbacks of Ovarian Transposition:-Drawbacks of Ovarian Transposition:- 25% risk of benign ovarian cysts.25% risk of benign ovarian cysts. 50% ovarian failure.50% ovarian failure. Risk of occult metastasisRisk of occult metastasis

Ovarian Transposition



Cervical cancer - treatment

Radical hysterectomy, radiotherapy and chemoradiation are all radical modalities

Majority of cancers detected in younger women are early stage ? too radical for early disease ? can fertility be conserved


Extrafascial hysterectomy; pubocervical ligament is incised, lateral deflection of the ureter CIN, early stromal invasion

II- Removal of the medial half of the cardinal and uterosacral ligaments; upper third of the vagina removed Microcarcinoma postirradiation

III Removal of the entire cardinal and uterosacral ligaments; upper third of the vagina removed Stages Ib and IIa lesions




Class-II

Class-III

Class-I


ClassClass Type of Type of Surgical margins Surgical margins IndicationsIndications

HysterectomyHysterectomy

IVIV RadicalRadical ureter completely dissected ureter completely dissected Recurrent diseaseRecurrent disease

from cervico-vesical ligamentfrom cervico-vesical ligament

superior vesicle art. sacrificed superior vesicle art. sacrificed

3/43/4thth of vagina, of vagina, , ,

VV RadicalRadical Resection includes portion Resection includes portion Recurrent Recurrent diseasedisease of distal ureter and bladderof distal ureter and bladder

Extent of SurgeryFive classes of hysterectomy (Piver, 1974) cont..Five classes of hysterectomy (Piver, 1974) cont..


Less radical surgery Morbidity of the radical

hysterectomy and nodes comes from Lymphadenectomy

Lymphocele/lymphoedema, nerve/vessel injury

Parametrectomy Damage to autonomic nerve fibers

bladder, bowel and sexual dysfunction Late urological/rectal dysfunctions: 20-30% 10www.zohrehyousefi.com

Post-operative Morbidity Febrile morbidityFebrile morbidity

Bladder dysfunctionBladder dysfunction

Fistulae – VVF, UVFFistulae – VVF, UVF

Ureteric stenosisUreteric stenosis

Neuropathies Neuropathies

Thrombo-embolismThrombo-embolism

LymphocystLymphocyst

Lower limb edemaLower limb edema

GI complicationsGI complications


Less Radical Surgery

Review of 1063 cases of stage IA2

Rate of lymph node mets: < 5% 12% in ptes with LVSI + 1.3% in ptes with LVSI –

Recurrence rate: 3.6%Van Meurs H et al. Int J Gynecol Cancer 19: 21, 2009


Less Radical Surgery

In low risk disease Stage Ib1

< 2 cm LVSI -

Rate of lymph node metastasis: < 5%

Kinney WK. Gynecol Oncol 57:3-6, 1995


Stage IA1Stage IA1 <0.5%<0.5%

Stage IA2Stage IA2 8% (0-13%)8% (0-13%)

Stage IBStage IB 12-20%12-20%

Stage IIAStage IIA 20-38%20-38%

Pelvic LN Metastasis in Early Cervical Ca



Adjuvant Treatment after RHAdjuvant Treatment after RH

Risk factors Risk category

Adjuvant Rx

Nil Low Risk None

Deep stromal

invasion

Tumor >4 cm

LVSI

Intermediate

Risk

Adjuvant pelvic

RT*

Lymph node

Cut margin

Parametrium

High Risk Adjuvant

Concurrent CT +

RT ****Peters et al. J Clin Oncol.2000**Peters et al. J Clin Oncol.2000 **Sedlis et al. Gynecol Oncol.1999Sedlis et al. Gynecol Oncol.1999

any two

any one


Less radical surgery Parametrial invasion

Literature review of ptes with low-risk pathological

characteristics: Tumor size < 2 cm Stromal invasion < 10 mm Negative pelvic nodes No LVSI

Risk of PI was 0.63% (5/799)

Stegeman et al. Gynecol Oncol 2007; 105: 475 17www.zohrehyousefi.com

Less radical surgery Sentinel node mapping

Particularly effective in small lesions (< 2 cm)

Detection rate: 100% False negative rate: 0%

Could reduce the radicality/morbidity of the PLND in this low risk groupRob L et al. Gynecol Oncol 98: 281, 2005


Less radical surgery Relationship between SN vs PI

status 158 ptes IA2/IB1

If SN +: risk of PI 28% If SN - : risk of PI 0% if

Tumor < 2 cm Stromal invasion < 50%

Strnad P et al. Gynecol Oncol 2008; 109: 280


Parametrial SN

Right obturator SNRight parametrial SN

Ureter

uterine artery

Sup. vesical artery Obturator nerve


radical trachelectomy for cervical cancer


The formal name of this operation is radical vaginal trachelectomy (RVT) and also known as the Dargent operation and radical trachelectomy.


Trachelectomies, broadly, can be divided into the simple and radical variants.


A simple trachelectomy refers to the removal of the cervix; this can be considered to be a very large conization procedure


Radical resection of the primary tumor with an Radical resection of the primary tumor with an adequate clear margin +/- lymphadenectomyadequate clear margin +/- lymphadenectomy

Types of surgeryTypes of surgery Stage of the diseaseStage of the disease

ConizationConization Stage IA1 without Stage IA1 without LVSI LVSI

Conization with BPLNDConization with BPLND Stage IA1 with LVSI Stage IA1 with LVSI

Radical Trachelectomy with BPLND Radical Trachelectomy with BPLND Stages IA2-IB1, Stages IA2-IB1, IA1 with LVSI IA1 with LVSI

Trachelectomy Trachelectomy LymphadenectomyLymphadenectomy

Fertility Preserving Surgeries

Vaginal Laparoscopic

Extra-peritoneal

Abdominal25www.zohrehyousefi.com



Radical trachelectomy

Indications Women under 40 Cancers up to Stage Ib (IIa)

Strong desire to maintain fertility


Over 90 carried out at St Bartholomew’s Hospital

3 recurrences and 1 death26 live births


What is done?What is done?

One stage procedurePelvic Lymphadenectomy and Trachelectomy

Two stage procedurePelvic Lymphadenectomy and if nodes negativeThen Trachelectomy


LymphadenectomyLymphadenectomy

Intraperitoneal

Extraperitoneal

Laparoscopic

As the principle is to preserve fertility logically The intra-peritoneal approach should be avoided.


Radical trachelectomy.. Pelvic lymphadenectomyPelvic lymphadenectomy

Frozen sectionFrozen section

Negative Nodes Negative Nodes

Radical trachelectomyRadical trachelectomy

If resection margins positive / nodes positiveIf resection margins positive / nodes positive

Radical hysterectomyRadical hysterectomy

Cervical circlage suture to ↓Cervical circlage suture to ↓ the risk of abortion. the risk of abortion.


Radical trachelectomy

•Dargent et al, 1994

•Cx + parametrium + upper vagina removed

•Pelvic lymphadenectomy

•Isthmic-vaginal anastomosis

•Isthmic cerclage


Radical trachelectomy-Radical trachelectomy-Obstetric considerationsObstetric considerations

Contraception for 6-12 mths.Contraception for 6-12 mths.

↑↑second trimester abortions, second trimester abortions, premature rupture of membrane, premature rupture of membrane, choriamnionitis, and preterm deliveries.choriamnionitis, and preterm deliveries.

Delivery by elective Delivery by elective classical classical caesarean caesarean section. section.


Radical trachelectomy -follow-up

CYTOLOGY IS CRUCIAL IN FOLLOW-UP Isthmic-vaginal smears are taken using

brush and spatula 3 monthly in first year 4 monthly in second year 6 monthly from 2-5 years annually thereafter till 10 years

After 10 years, discharged and sent to NHSCSP call-recall programme


PregnancyPregnancy

Pregnancy can be achieved But

25% chance of miscarriage30% + risk of premature labour100% risk of Caesarean Section


Early Stage Disease Preservation of Fertility

Radical Trachelectomy and extra-peritoneal Pelvic Lymphadenectomy

Shepherd et al. 1998, 10 cases, 6 pregnancies, 3 births.Darent et al 2000 47 cases, 13 births miscarriage rate 25%

Roy, 1998 30 cases, 6 attempted pregnancy, 4 successful

Follow-up is limited and numbers are small but no majorindications to cease this approach in carefully selected patients.


Summary Trachelectomy represents

conservative surgical approach for early stage invasive cervical

cancer Likely to increase in popularity Cytology is mainstay of follow-

up Essentially cytological features

are predictable and similar to those after cone biopsy 38www.zohrehyousefi.com


Documents

1 Less Radical Surgery for Patients with Early-Stage Cervical Cancer Dr.Yousefi Professor Mashhad University of Medical Sciences