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SURGICAL MANAGEMENT OF CARCINOMA CERVIX
Ashish Tripathi
Investigation: Establishing the Dx
General physical examination including examination of supraclavicular,axillary and inguinofemoral lymph nodes.
Colposcopy Cervicography Cervical biopsy Conisation Endocervical canal curettage
CERVICAL BIOPSYCERVICAL BIOPSY
Colposcopy available : biopsy from suspicious area If not: employing iodine solution Shiller’s 0.3%,
lugol’s iodine and Acetic acid. Types:
– Surface biopsy– Punch biopsy– Wedge biopsy– Ring biopsy– Cone bipsy
CONIZATIONCONIZATION
Both diagnostic and therapeutic purpose Removal of cone of the cervix which includes
Squamocolumnar junction, stroma with glands and endocervical mucous membrane.
Methods: Cold knife, CO₂ laser, Laser diathermy loop Indication:
– Unsatisfactory colposcopic findings– Inconsistent findings– Positive endocervical curettage for CIN II and III– Biopsy shows microinvasion – to exclude gross invasive
carcinoma
Testing To Identify:
Laboratory
CBC Anaemia prior to surgery, chemotherapy or radiotherapy
Urinalysis Hematuria
Liver function Liver metastasis
Creatinine and BUN levels Hydronephrosis
Investigation Used during Cervical Cancer Staging
Radiologic Chest radiograph Lung metastasis Intravenous pyelogram (IVP) Hydronephrosis
CT scan (abdomen and pelvis) Lymph node metastasis, metastasis to other distant organs, and hydronephrosis
MR imaging Local extracervical invasion + those for CT scan
PET scan Lymph node metastasisProcedural Cystoscopy Tumor invasion into the bladder Proctoscopy Tumor invasion into the rectum
Examination under anesthesia
Investigations for management
CBC, Hb Serum Urea, Creatinine
LFT, RFT CXR – PA view CT, MRI, Abdomino-pelvic USG Lymphangiography Biopsy and histopathologic evidence of invasive
malignancy should precede any treatment modality.
Surgery:General Considerations patients with FIGO stage I to IIA cervical cancer
Operable growth: Smaller tumors, not fixed to the pelvic wall and no distant metastasis
Those who are physically able to tolerate an aggressive surgical procedure
Those who wish to avoid the long-term effects of radiation therapy
Radio-resistant growth.
Typical candidates include young patients who desire ovarian preservation.
Retention of a functional, non-irradiated vagina.
Women with pelvic masses, pelvic infections, chronic salpingitis, extensive bowel adhesion from previous peritonitis, endometriosis.
Classification of extent of operation1. (Type I ) extrafascial hysterectomy
2. (Type II) modified radical hysterectomy/ Wertheim hysterectomy
3. (Type III) radical hysterectomy/ Meigs-Wertheim hysterectomy
4. (Type IV) extended radical hysterectomy
5. Type V operation: exenteration
Simple Hysterectomy (Type I)
Also known as an extrafascial hysterectomy or simple hysterectomy, removes the uterus and cervix, but does require excision of the parametrium or paracolpium.
It is appropriately selected for benign gynaecologic pathology, preinvasive cervical disease, and stage IA1 cervical cancer.
Modified Radical Hysterectomy (Type II)
Modified radical hysterectomy removes the cervix, proximal vagina, and parametrial and paracervical tissue.
This hysterectomy is well suited for tumors with 3- 5mm depths of invasion and smaller stage IB tumors.
Radical Hysterectomy (Type III) Requires greater resection of the
parametria, and excision extends to the pelvic sidewall .
The ureters are completely dissected from their beds, and the bladder and rectum are mobilized to permit this more extensive removal of tissue. In addition, at least 2 to 3 cm of proximal vagina is resected.
This procedure is performed for larger IB lesions, and for patients with relative contraindications to radiation such as diabetes, pelvic inflammatory disease, hypertension, collagen disease or adnexal masses.
Type IV - Extended radical hysterectomy – Removal of all periureteral tissue, superior vesicle artery
and ¾ of vagina.– Indication: Anteriorly occurring central recurrences
where preservation of bladder still possible.
Type V - Exenteration – Portion of ureter and bladder are also dissected.– Indication: Central recurrent cancer involving portion
of the distal ureter or bladder.
Patient Preparation T/t and control of systemic illness like DM,HTN. PAC and consultation with anesthesiologist.
Blood grouping and cross matching with adequate Mx of blood for transfusion if required.
Mini-heparisation: s/c heparin 5000IU tid 8-24 hrs prior to SX.
Bowel preparation. Prophylactic antibiotics. Optimal RFT, Resp.FT and LFT.
Management of Invasive Cancer of the Cervix
Stage Ia1
≤3 mm invasion, no LVSI Conization or type I hysterectomy
≤3 mm invasion, w/LVSI Radical trachelectomy or type II radical hysterectomywith pelvic lymph node dissection
la2 >3–5 mm invasion Radical trachelectomy or type II radical hysterectomywith pelvic lymphadenectomy
lb1 >5 mm invasion, <2 cm Radical trachelectomy or type III radical hysterectomywith pelvic lymphadenectomy
>5 mm invasion, >2 cm Type III radical hysterectomy with pelviclymphadenectomy
lb2 >5 mm invasion Type III radical hysterectomy with pelvic and paraaorticlymphadenectomy or primary chemoradiation
Stage IIa Type III radical hysterectomy with pelvic and paraaorticlymphadenectomy or primary chemoradiation
IIb, IIIa, IIIb Primary chemoradiation
Stage IVa Primary chemoradiation or primary exenteration
IVb Primary chemotherapy ±6 radiation
LVSI: lymphovascular space invasion
Complications of Radical Hysterectomy
Acute Complications
1.Blood loss (average, 0.8 L) and shock
2.Ureterovaginal fistula (1% - 2%)
3.Vesicovaginal fistula (1%)
4.Pulmonary thrombo-embolism (1% - 2%)
5.Small bowel obstruction, ileus (1%)
6.Sepsis, pelvic cellulitis (7%) and urinary tract infection (6%). Wound infection, pelvic abscess, and phlebitis in <5% of patients.
7.Damage to adjacent organs
Subacute complications
Postoperative bladder dysfunction, ureteric fistula, urine retention.
Lymphocyst formation.
Chronic complications
Bladder hypotonia
Bladder Atony
Ureteric strictures :rare
Palliative care Radiotherapy and Chemotherapy
Pain Management– Intrathecal injection of phenol– Analgesics
Good nursing care
Psychological and physical support
Follow up
References:
Howkins & Bourne Shaw’s Textbook of Gynaecology,14th edition
Novak’s Gynaecology,14th edition
Williams’ Gynaecology,