SURGICAL MANAGEMENT SURGICAL MANAGEMENT OF CARCINOMA CERVIXOF CARCINOMA CERVIX

Dr.A.KALAICHELVI. MD ;DGO ;DNB.Dr.A.KALAICHELVI. MD ;DGO ;DNB.Professor of OBGYN & Microsurgery.Professor of OBGYN & Microsurgery.

Kilpauk Medical College and Kilpauk Medical College and Hospital. Hospital.

INTRODUCTION

• Worldwide Carcinoma Cervix is the most common cancer affecting women after Breast cancer

• The incidence is higher in developing countries where about 2 lakh people die each year

• The disease has a relatively long natural history • Invasive cancer is considered a preventable disease• With cervical cytology screening programmes

preinvasive lesions can be detected earlier • Treatment in the pre-invasive phase is highly

effective

Changing Scenario

CURE

CARE

CANCER Rx Revolution

PRINCIPLES OF TREATMENT OF PRINCIPLES OF TREATMENT OF PREINVASIVE LESIONSPREINVASIVE LESIONS OF OF CERVIXCERVIX• Management of CIN is based on the natural history Management of CIN is based on the natural history

of the disease.of the disease.• CIN ICIN I in younger women are often transient. 10-15% in younger women are often transient. 10-15%

progress to high grade. Needs only follow up in low progress to high grade. Needs only follow up in low resource setting. If it persists for 2 years or more it resource setting. If it persists for 2 years or more it should be treated.should be treated.

• CIN 2 and 3CIN 2 and 3 true cancer precursors. High possibility true cancer precursors. High possibility of progression to invasive cancer.of progression to invasive cancer.

• 10-30% with 10-30% with LSILLSIL on cytology will have CIN 2 and3 on cytology will have CIN 2 and3 in biopsyin biopsy

• 1-2% with 1-2% with HSILHSIL will have invasive cancer. Hence the will have invasive cancer. Hence the treatment depends on histological classification of treatment depends on histological classification of lesion.lesion.

TREATMENT OF CINTREATMENT OF CIN• ExpectantExpectant follow up after ruling out invasion and follow up after ruling out invasion and

histological confirmation .histological confirmation .• Ablative therapyAblative therapy if entire lesion is visible, TZ if entire lesion is visible, TZ

should be identified and no suspicion of glandular should be identified and no suspicion of glandular lesion on cytology /histologylesion on cytology /histology

Laser CO2Laser CO2 CryotherapyCryotherapy Cold coagulationCold coagulation ElectrocauteryElectrocautery ElectrocoagulationElectrocoagulation• Excision Excision Punch biopsyPunch biopsy ConizationConization LEEP/LLETZLEEP/LLETZ HysterectomyHysterectomy

ABLATIVE PROCEDURESABLATIVE PROCEDURES

Principle: Eradication of abnormal Principle: Eradication of abnormal epithelium and prevent its recurrence epithelium and prevent its recurrence with least morbiditywith least morbidity

Cryotherapy :Cryotherapy : Rapid freezing causes Rapid freezing causes crystallization of cell water leading to crystallization of cell water leading to cell dehydration and protein coagulationcell dehydration and protein coagulation

• We use compressed gas cylinder (N2O We use compressed gas cylinder (N2O or CO2) cryogen with metal probes. or CO2) cryogen with metal probes.

• Depth of destruction - 5mm. Depth of destruction - 5mm.

CO2 laser vaporization-CO2 laser vaporization- high high intensity beam - tissue vapourization intensity beam - tissue vapourization - boiling of intracellular water and - boiling of intracellular water and explosion of cell. Incineration of explosion of cell. Incineration of protein and mineral - charring of the protein and mineral - charring of the treated area.treated area.

• Depth of destruction - 6-7mmDepth of destruction - 6-7mm

Rapid healing with minimal fibrosis.Rapid healing with minimal fibrosis.

• ElectrocauteryElectrocautery - oldest method. - oldest method.

• Depth of destruction only 2-3 mm. Depth of destruction only 2-3 mm. Residual lesion always present. Residual lesion always present. No tissue is available for HPE. No tissue is available for HPE.

• Electrocoagulation diathermyElectrocoagulation diathermy : : Deep coagulation of cervical stroma Deep coagulation of cervical stroma with needle electrodes and with needle electrodes and destruction with ball electrodes.destruction with ball electrodes.

• Healing in 4 weeks.Healing in 4 weeks.

CRYOTHERAPYCRYOTHERAPY

PROSPROS

1.1. Office procedureOffice procedure

2.2. Easy no expertise Easy no expertise neededneeded

3.3. No need for No need for anaesthesiaanaesthesia

4.4. Cure rate better with Cure rate better with 1 or 2 quadrant 1 or 2 quadrant lesionlesion

CONSCONS

1.1. Uterine cramp and Uterine cramp and painpain

2.2. Watery discharge per Watery discharge per vaginumvaginum

3.3. Slight spotting Slight spotting

4.4. InfectionInfection

5.5. Tissue for HPE not Tissue for HPE not available.available.

6.6. Cervix stenosis 1-4%Cervix stenosis 1-4%

CO2 laser vaporizationCO2 laser vaporization

PROSPROS1.1. Healing is rapidHealing is rapid2.2. Limited vaginal Limited vaginal

dischargedischarge3.3. Less cervix Less cervix

narrowingnarrowing4.4. No diminution of No diminution of

fertilityfertility5.5. No obstetric No obstetric

complicationcomplication

CONSCONS1.1. ExpensiveExpensive2.2. Needs expertiseNeeds expertise

EXCISION TECHNIQUESEXCISION TECHNIQUES

• LLETZ or LEEP- LLETZ or LEEP- to remove the to remove the entire TZ along with the lesionentire TZ along with the lesion

• The excision of TZ treats the The excision of TZ treats the abnormality and specimen is abnormality and specimen is available for HPE.available for HPE.

• Width of the loop-10-20mmWidth of the loop-10-20mm• Depth of the loop- 8-15mmDepth of the loop- 8-15mm• Local anaesthesiaLocal anaesthesia

• Before procedure Before procedure colposcopycolposcopy repeated repeated and Lugol’s iodine applied to delineate and Lugol’s iodine applied to delineate the margin of the lesions.the margin of the lesions.

• ComplicationsComplications- bleeding, cervical - bleeding, cervical stenosis <2%stenosis <2%

• Upto 20% post LLETZ specimen may Upto 20% post LLETZ specimen may have disease at the margin on follow have disease at the margin on follow up.up.

• Failure rate 4-10%Failure rate 4-10%

LLETZLLETZ

PROSPROS

1.1. Local anaesthesiaLocal anaesthesia

2.2. Tissue for HPE gotTissue for HPE got

3.3. Easy to use/ Easy to use/ teach/applyteach/apply

4.4. Low costLow cost

CONSCONS

Thermal artifact in Thermal artifact in tissuetissue

COLD KNIFE CONE COLD KNIFE CONE BIOPSYBIOPSY

• For microinvasive cancer where For microinvasive cancer where evaluation of margin is important.evaluation of margin is important.

• Local anaesthesiaLocal anaesthesia

Incision should be made posteriorly and Incision should be made posteriorly and then carried anteriorly. then carried anteriorly.

• Depth - 15-20mm Depth - 15-20mm

• If cone margin +ve -22% residual lesionIf cone margin +ve -22% residual lesion

• If cone margin –ve 4% residual lesionIf cone margin –ve 4% residual lesion

• Complications- haemorrhage, sepsis, Complications- haemorrhage, sepsis, infertility, stenosis infertility, stenosis

Contd..Contd..

PROSPROS

1.1. Tissue for HPETissue for HPE

2.2. No thermal artifactNo thermal artifact

3.3. Suitable for Suitable for endocervical endocervical glandular glandular involvementinvolvement

CONSCONS

1.1. Cervical Cervical incompetence and incompetence and stenosisstenosis

2.2. Expensive Expensive

3.3. Performed under Performed under anaesthesia in anaesthesia in theatretheatre

HYSTERECTOMYHYSTERECTOMY

• INDICATIONSINDICATIONS

1.1.Associated Gynaecological ConditionsAssociated Gynaecological Conditions

2.2.Persistent Abnormal Smear Following Persistent Abnormal Smear Following Excision or Ablative ProcedureExcision or Ablative Procedure

3.3.Positive Endocervical margin after Positive Endocervical margin after ConisationConisation

INVASIVE LESIONS OF CERVIXINVASIVE LESIONS OF CERVIXTREATMENT OPTIONSTREATMENT OPTIONS

• RT all stages.RT all stages.

• Surgery – Limited to stage Ia to stage Surgery – Limited to stage Ia to stage IIa.IIa.

• 5yr survival rate stage I -85% RT/RH.5yr survival rate stage I -85% RT/RH.

• Lesions >4cm needs postop.RT- Lesions >4cm needs postop.RT-

• Ovary metas.- 0.5% scc Ovary metas.- 0.5% scc

= 1.7%Adenocarcinoma. = 1.7%Adenocarcinoma.

SAME Rx – ALL HISTOLOGICAL TYPESSAME Rx – ALL HISTOLOGICAL TYPES

FACTORS INFLUENCING THE FACTORS INFLUENCING THE CHOICE OF TREATMENT OF CA CHOICE OF TREATMENT OF CA CXCX• AgeAge• Desire for fertility preservationDesire for fertility preservation• Tumor sizeTumor size• StageStage• HistologyHistology• Evidence of lymph node metastasisEvidence of lymph node metastasis• Risk factors for complication of surgeryRisk factors for complication of surgery• Presence of other comorbiditiesPresence of other comorbidities• Patient preferencePatient preference

TREATMENT MODALITIESTREATMENT MODALITIES

• STAGE IA1 STAGE IA1 Superficial invasive lesion Superficial invasive lesion <3mm <3mm

Conisation-follow up- If margin +ve Conisation-follow up- If margin +ve repeat conisation or hysterectomy.repeat conisation or hysterectomy.

or or

Extra fascial hysterectomy (type I)Extra fascial hysterectomy (type I)

• Pelvic LN mets <1% so, no need for pelvic Pelvic LN mets <1% so, no need for pelvic lymphadenectomy.lymphadenectomy.

• Early stage IA2, IB1 ,IB2 and small IIA Early stage IA2, IB1 ,IB2 and small IIA – (type II hysterectomy) modified – (type II hysterectomy) modified radical hysterectomy (WERTHEIM’S) radical hysterectomy (WERTHEIM’S) or Radiotherapyor Radiotherapy

• Locally advanced stage IB2 – IVA -Locally advanced stage IB2 – IVA -concurrent chemo radiationconcurrent chemo radiation

• Central recurrence after RT- Central recurrence after RT- Exenteration surgeryExenteration surgery

• Isolated pelvic recurrence after Isolated pelvic recurrence after hysterectomy-hysterectomy- radiotherapy radiotherapy

BASIC INVESTIGATIONSBASIC INVESTIGATIONS

• A detailed history and clinical examination • Complete haemogram• RFT• LFT• Chest X Ray• USG abdomen and pelvis • CT abdomen and pelvis • Cervix biopsy to confirm the diagnosis

TREATMENT of superficially TREATMENT of superficially invasive Ca cervix invasive Ca cervix (microinvasive disease) Stage (microinvasive disease) Stage IA1& IA2IA1& IA2• Stage IA1 without LVSI- Stage IA1 without LVSI- therapeutic therapeutic

conization if cone margin negativeconization if cone margin negative

• With LVSI- With LVSI- Radical Trachelectomy or Radical Trachelectomy or Type-II Hysterectomy with BPLN Type-II Hysterectomy with BPLN Dissection.Dissection.

Stage IA2Stage IA2

• Stromal invasion - 3-5mmStromal invasion - 3-5mm

• Nodal involvement - 5%Nodal involvement - 5%

• Modified radical hysterectomy with Modified radical hysterectomy with BPLN Dissection/Radical Trachelectomy.BPLN Dissection/Radical Trachelectomy.

• Lesion<2cm , no LVSI , Negative nodesLesion<2cm , no LVSI , Negative nodes—Ideal for Radical Trachelectomy.—Ideal for Radical Trachelectomy.

• Complications – Complications – ABORTION , PREMATURITY , PTL .ABORTION , PREMATURITY , PTL .

STAGE IB1 , IB2 AND IIASTAGE IB1 , IB2 AND IIA

• Radical hysterectomy with bilateral Radical hysterectomy with bilateral pelvic lymphadenectomypelvic lymphadenectomy

• To destroy malignant cells in the To destroy malignant cells in the cervix, paracervical tissues and cervix, paracervical tissues and regional lymph nodesregional lymph nodes

• High risk features benefit from post High risk features benefit from post op RT or chemoradiationop RT or chemoradiation

For Stage IB2 diseaseTreatment modalities

a. Radical surgery alone b.

NACT-(Cisplatin40mg/cycle+5 FU 500mg/cycle) for 4 cycles pre op + Radical surgery

c. Concurrent chemoradiation d. Preop RT followed by RH

Advantages of NACT followed by RH

• Upfront chemotherapy might decrease tumour volume thereby improving resectability and also reduces surgical morbidity by downstaging of lesions.

• Chemotherapy also eliminates microscopic metastatic disease.

• So, it is a potential viable alternative when there is no access to Radiotherapy or there are delays in delivery of Radiotherapy.

• But the potential benefit of Neoadjuvant chemotherapy for patients with early stage adenocarcinoma is unknown

• Neoadjuvant chemotherapy appears to improve overall survival and progression free survival in locally advanced Carcinoma Cervix.

• It also appears to reduce local and distant recurrence.

• Excellent survival results are achievable when screening is combined with appropriate surgical management.

Types of hysterectomy (RUTLEDGE CLASSIFICATION)

•CLASS 1-Extrafacial hysterectomy

•CLASSII-Modified radical hysterectomy (Werthiems). Uterus, paracervical tissues, upper vagina1-2cm

•Medial half of parametrium &proximal uterosacrals resection

•TYPE III –RH Enbloc removal of uterus, upper1/3 vagina, paravaginal & paracervical tissues.

•Bilateral resection of parametrium upto pelvic sidewall.

•Removal of as much uterosacrals as possible.

•TYPE IV-Extended RH

•TYPE V- Partial Exenteration.

SALIENT STEPS OF WERTHIEMS HYSTERECTOMY

•Division of round ligaments & infundibulo pelvic ligaments.

•Dissection of paravesical space

• Isolating &dissecting the ureters & dissection of para rectal space.

•Ligating uterine arteries at their origin.

•Dissecting ureteric tunnels & displacing ureters laterally

•Dissecting rectovaginal space

•Excising uterosacral ligaments & vaginal cuff.

Completing Bilateral pelvic lymphadenectomy.

COMPLICATIONSCOMPLICATIONS

Intraoperative and immediate post op Intraoperative and immediate post op complicationscomplications

• Blood lossBlood loss• Uterovaginal 1-2%Uterovaginal 1-2%• VVF <1%VVF <1%• Pulmonary embolus 1-2%Pulmonary embolus 1-2%• Small bowel obstruction 1-2%Small bowel obstruction 1-2%• Fever- thromboembolism, cellulitis, UTI, Fever- thromboembolism, cellulitis, UTI,

wound infection.wound infection.• Lymphocyst formationLymphocyst formation

CONTRAINDICATIONS•Severe heart disease: unstable angina, congestive cardiac failure, recent myocardial infarction.

•Severe pulmonary disease

•Active thrombotic disease

•Old age

•obesity

Postoperative management

•Survival depends on intermediate

& high risk pathological factors have 30 & 40% risk of

recurrence within 3 yrs.

Survival rate depends on following factors:

1.Lesion size (<2cm=90% . >4cm=40%.) 2.Depth of invasion

(<1cm=90% . >1cm=63-78%) 3.Parametrial spread (- ve=95% . +ve=69%)

4.LVSI (Absent=95% . present=50-70%)- predictor of lymph node metastasis. 5.Lymphnodes-

pelvic nodes=65%.common iliac=25%

RISK FACTORS

• Intermediate High risk Large size +ve margin

Stromal invasion +ve nodes LVSI Microscopic

Parametrial Involvement

•NEED ADJUVANT RADIOTHERAPY/

CHEMORADIATION

OTHER TYPESOTHER TYPES

•Vaginal radical hysterectomy & BPLN. Schouta mitra surgery.-UV prolapse and CA Cx

•Lap. assisted radical vaginal hysterectomy.

•Okabayashi’s nerve sparing RH.

• Role of sentinel node evaluation.

CA CERVIX DURING PREGNANCY

CIN – Colposcopy – LSIL – PP 12 weeks HSIL – PP 6 Weeks If suspicious of invasion – colposcopy

directed punch biopsy. Cis-0.013% 1st AN visit- pap ,

colposcopy-biopsy-invasive lesion –conization (diag)->abortion 1st trim.-33%.

Tmt –differed till 12weeks after childbirth.

• INVASIVE LESION- RARE 0.5-5%

• Invasion < 3mm & no LVSI – Delivery – VH After 6 weeks

• Invasion 3-5 mm & LVSI – CS - RH

•StageIB1-classical CS – RH•StageIB2-1st trim-RT-SPON.ABORTION.

2nd trim. -delay for fetal maturity - - RT

•Stage II -IV- RT

OVARIAN CANCER

What constitutes high risk?Risk increases with age after 40yrs. 15-16/100,000.Peak rate of 57/100,000 in 70-74yrs of age. High risk – Nulliparity Hereditary breast/ovarian cancer syndrome HNPCC BRCA1 & BRCA2-mainly breast cancer but also to ovarian cancer Familial ovarian cancer (2 or more affected. 1stor 2nd degree relatives with epithelial ovarian cancer)

What is the most appropriate screening method?Multimodality study-Annual RV examination.Ca 125

with TVS Ca 125 - serial measurements. Specificity – 99.7% Sensitivity – 83% Positive predictive value - 16% Ca 125>35U/ml – abnormal Repeat 2-3 months later. Progressive rise

in Ca 125 > 95U/ml or doubling the level over 3 months are abnormal.

Ca 125 increases in- breast cancer, lung ca, colorectal ca, pancreatic and gastric cancers.

USG: TVS Simple ovarian cysts <2 cm

repeat 2-3 months later Multi cysts , thick septa,

excrescences or irregular patterns, sonolescency of the tumor are features of greater malignant potential.

What is the age to commence screening?

For high risk women- 25-30 yrs of age

BRCA1 mutation- 10 yrs earlier (35 yrs)

BRCA2 mutation- 45 yrs

Is screening the best way to manage risk and what are the alternatives

• For carriers of BRCA1 mutation – 35-40 yrs Prophylactic salphingo oophorectomy

• For BRCA2 carriers 45-50yrs.

• Hysterectomy with BSO would eliminate the need to use HRT.

• OC pills- increased risk for breast cancer in mutation carriers

MANAGEMENT OF EARLY STAGE EOC (FIGO stage I & II)What is the rationale of primary

cytoreductive surgery on patients with suspected ovarian cancer?

1. Diagnosis 2. Staging 3. Palliation 4. Cytoreduction

•The FIGO stage is a major prognostic factor so exact surgicopathological assessment of spread of disease is important for counseling the patient regarding her prognosis and choosing the adjuvant therapy. Palliation of symptoms like pain, nausea and vomiting and improved nutritional status

What are the guidelines for

surgical staging? 1. Vertical abdominal incision-

enlarged supraumblical2. Ascites- for cytology If no ascites- peritoneal washings

with 100-150 ml of saline solution.

3. Abdominal organs are inspected. Entire peritoneal surface of the

abdominal wall from pelvis to diaphragm-palpated for tumor implants.

4. Resection of primary ovarian cancer- TAH with BSO.

5. Infracolic omentectomy- as a staging procedure and as a part of surgical therapy.

Omental involvement- 5% If the tumor implants in the

omentum- total omentectomy

What is the rationale of omentectomy?

1.Greater omentum is the most common site of metastasis & greater omentectomy is done.

2.Omental cake contributes significantly to ascites. Its removal even as palliative procedure significantly reduces ascites and improves patients nutritional status in advanced disease.

3.Omental tumor excision is an important aspect of cytoreduction and increases the response to CT.

4.Omentectomy reactivates the host’s immune mechanism

6. Biopsies of pelvic peritoneum and abd peritoneum including paracolic gutters and diaphragmatic surface.

7. Appendicectomy controversial Mucinous tumors-8% of appendix

involved It can be the only site of extra

ovarian spread in patients with EOC Metastasis to appendix- 21% stage III,

50% stage IV.8. Stage 1: lymphatic spread 5-20%. Lymphadenectomy- not of prognostic

value. Hence not done as a routine.

ADJUVANT CHEMOTHERAPY

Stage IA or IB, G I- good prognosisStage IC or Grade 3, Stage II- Adjuvant CT 30-40% risk of recurrence in 5yrs.Stage IA or IB, Grade 3& IC & II- poor prognosis

6 cycles of Paclitaxel and Carboplatin Should all improperly surgically staged

patients be restaged.

When is restaging indicated?

•Stage Ia, Ib, Ic, G1&G2- mucinous, serous & endometroid.

•Stage Ia, Ib, Ic, G3& undifferentiated tumours

•Stage Ia, Ib, Ic, clear cell adenocarcinomas

What is the Criteria for conservative surgical management?

# Young patient desirous of future child bearing

# No evidence of dysgenetic gonads# Specific situations: -any unilateral malignant germ cell

tumour -any unilateral stromal tumour -any unilateral borderline tumour Stage IA invasive epithelial tumour

BORDERLINE TUMORS

#Borderline tumors 5-15% of all epithelial tumors.

# 55% - mucinous tumors.# Absence of stromal invasion- absolute criteria

to make diagnosis# FIGO & NCI guidelines recommend that

borderline tumors should be staged according to the FIGO classification.

# Presence of implants (micro/invasive) is the single most risk factor at the time of diagnosis.

# Fertility sparing surgery is an acceptable option in stage 1 disease.

MANAGEMENT OF ADVANCED DISEASE(Stage III &IV)

What is Interval cytoreductive surgery and when is it used? (IDS)

IDS after 3 cycles of chemotherapy is a

management option for patients with advanced ovarian cancer. Useful in

# Patients who are not suitable for primary cytoreductive surgery, going in for poor performance status, medical co morbidities or extent of disease.

# Patients who underwent primary cytoreductive surgery with suboptimal cytoreduction.

What is optimal and suboptimal debulking surgery?

•Optimal : <1cm of tumor residual volume

•Suboptimal: >1cm of residual tumor volume

What is the selection criteria for IDS?

For stage III & IV patients with >2cm residual disease – optimal debulking surgery is achieved in 64-83%.

It is based on the response to chemotherapy preoperatively.

Overall and progression free survival is significantly increased after IDS.

NEOADJUVANT CHEMOTHERAPY What is the Selection criteria for NACT # CT scan findings (Nelson’s criteria) presence of omental deposits. presence of ascites. presence of peritoneal deposits. # Histopathological report of malignancy. # Patients COPD, myocardial infarction, age

>75yrs, with large ascites, severe malnutrition( serum albumin <8gms/dl) and weight loss > 10-15 % of total body weight.

Chemotherapy used: 3 cycles of cisplatin and cyclophosphamide.

What are the advantages of NACT?1. Shrinking of the tumor mass, thereby

increasing the optimal debulking rate.2. Create better operative plane with adjacent viscera. 3. Decreases perioperative morbidity. 4. Shorter operative time, reduced blood loss

and hospitalization days. 5. Improves quality of life.

PLAN OF MANAGEMENT FOR STAGE III&IV

3 cycles of NACT interval debulking surgery3 cycles of adjuvant chemotherapy

Pelvic and para-aortic lymhadenectomy is indicated in all cases of advanced ovarian malignancies.

What is the criteria for secondary cytoreductive surgery?

# Recurrent ovarian cancer- completion of primary surgery and chemotherapy with clinical, radiological and serological disease free interval of 6 months.

# Rising Ca125 levels.# Absence of hepatic extra-abdominal

metastasis.# Patients performance status <4

GERM CELL TUMOURS:

Premenarchal : adnexal mass >2cmkaryotypeSurgery

Postmenarchal: # cyst <8cm , negative tumour markers

# cyst >8cm,solid,suspicious Observation for 6-8weeks ↓ ↓ inc in size dec in size ↓ ↓ surgery follow up

TUMOUR MARKERS:

AFPhCGLDHPLAPSurgical staging is important to determine

the extent of disease and for giving Adjuvant chemotherapy. Routine biopsy of the remaining ovary should be avoided, which may lead to adhesion formation, ovarian failure and infertility.

Restaging is not necessary because germ cell tumours are highly responsive to CT even at recurrence. Stage IA G1, pure immature teratoma

Stage I pure dysgerminoma : Surgery alone.

For all other patients with non dysgerminoma tumours – postoperative chemo therapy is currently the standard treatment.

Combination of bleomycin, etoposide & cisplatin. BEP: 4 cycles

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