1 Less Radical Surgery for Patients with Early-Stage Cervical Cancer Dr.Yousefi Professor Mashhad...
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Less Radical Surgery for Patients with Early-Stage
Cervical Cancer
Dr.Yousefi Professor Mashhad University of Medical Sciences
Gynecologist Oncologist
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Ovarian Transposition
Extent of Hysterectomy
lymph node metastasis
Sentinel node mapping
radical trachelectomy
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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
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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
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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
Extent of Hysterectomy
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Extent of Hysterectomy
Class-II
Class-III
Class-I
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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..
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Parametrial SN
Right obturator SNRight parametrial SN
Ureter
uterine artery
Sup. vesical artery Obturator nerve
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radical trachelectomy for cervical cancer
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The formal name of this operation is radical vaginal trachelectomy (RVT) and also known as the Dargent operation and radical trachelectomy.
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Trachelectomies, broadly, can be divided into the simple and radical variants.
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A simple trachelectomy refers to the removal of the cervix; this can be considered to be a very large conization procedure
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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
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Radical trachelectomy
Indications Women under 40 Cancers up to Stage Ib (IIa)
Strong desire to maintain fertility
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Over 90 carried out at St Bartholomew’s Hospital
3 recurrences and 1 death26 live births
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What is done?What is done?
One stage procedurePelvic Lymphadenectomy and Trachelectomy
Two stage procedurePelvic Lymphadenectomy and if nodes negativeThen Trachelectomy
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LymphadenectomyLymphadenectomy
Intraperitoneal
Extraperitoneal
Laparoscopic
As the principle is to preserve fertility logically The intra-peritoneal approach should be avoided.
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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.
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Radical trachelectomy
•Dargent et al, 1994
•Cx + parametrium + upper vagina removed
•Pelvic lymphadenectomy
•Isthmic-vaginal anastomosis
•Isthmic cerclage
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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.
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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
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PregnancyPregnancy
Pregnancy can be achieved But
25% chance of miscarriage30% + risk of premature labour100% risk of Caesarean Section
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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.
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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
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