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,