Cervical Carcinoma and Surgery

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Cervical Carcinoma and Surgery
Sean Kehoe Professor of Gynaecological
Cancer Oxford.
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Background
Cervical Carcinoma affects 3500
women/year Most 75 will present with early
stage disease Recent audit indicates 20
detected on specimens from Loop cone of the
cervix for pre-invasive disease. Mortality Rate
lt1000/year England Wales
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The role of Surgery in Cervical Carcinoma
As a diagnostic procedure to obtain tissue As
a curative procedure To indicate the need for
adjuvant therapy
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Staging Cervical Cancer is Clinical
EUA biopsy Cystoscopy Sigmoidoscopy IVU CXR MRI
today commonly used. NB Stage Ib1, can have
disease within the lymph nodes Adjuvant therapy
given to such patients BUT the disease stage
remains the same So positive nodal 1b1 is
combined with negative node 1b1 even though 5
year survival for node is about 75 and node
about 50
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Types of Surgery
The most common type of Surgery is a Wertheims
Hysterectomy This includes Hysterectomy
Pelvic Lymphadenectomy Vaginal
Cuff Removal of ovaries not all cases
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When is Surgery Appropriate??
When all disease can be excised. When it alone
affords Cure Chemo-Radiotherapy is an
effective alternative to Surgery
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Chemo-radiotherapy in Cervical Cancer

• Morris et al, NEJM 1999 Pelvic radiation with
  concurrent chemotherapy
• compared with pelvic and para-aortic radiation
  for high risk cervical cancer.
• Rose et al NEJM, 1999 Concurrent cisplatin-based
  radiotherapy and
• chemotherapy for locally advanced cervical
  cancer.
• Keys et al. NEJM, 1999 Cisplatin, radiation and
  adjuvant hysterectomy
• compared with radiation and adjuvant hysterectomy
  for bulky stage IB
• Cervical carcinoma.

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Cervical Carcinoma.
Rose et al. Trial Chemo -Radiotherapy Cisplatin
vs Cisplatin/Flurouracil/Hydroxyurea vs
Hydroxyurea Patients - Stage IIB/III/IVA
without para-aortic lymph node involvement. 526
women, 176 vs 173 vs 177 Findings Relative Risks
shown Cisplatin Triple Hydroxyurea Prgression
/Death 0.57 0.55 1 Death
0.61 0.58 1 Local recurrences
19 20 30 Distant recurrences 3
4 10 Cisplatin best as equally effective
but with less side-effects compared with
combination.
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Cervical Carcinoma.
Keys et al. Bulky stage 1B - gt 4 cms in
diameter. Trial Radiotherapy vs
Chemoradiotherapy Cisplatin x 6 cycles all
followed by hysterectomy. 183 women radiotx, 186
combined. Findings Radiotherapy Chemoradiothe
rapy Residual disease at TAH 41
52 Rel. Risk of recurrence 1
0.51 Rel Risk Death 1 0.54 3 yr
survival 74 83 ?? value of
hysterecomy
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Cervical Carcinoma.
Morris et al. NEJM Patients stage II B - IV A
or I B/IIA with tumour diameter gt 5cms or
positive lymph nodes. Women with disease outside
pelvis excluded. Trial Pelvic/para-aortic
radiotherapy vs. Pelvic Flurouracil/Cisplatin 4
03 randomised, 193 evaluated in each
group Findings
Radiotherapy Chemo/Radiotherapy 5 year
Survival 58 73 Disease free
Survival 40 67 Distant relapse 33 14 Lo
cal relapse 35 19 all statistically
significant differences.
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Hysterectomy after ChemoRad?

• From all the studies there does not seem to be
  a role for routine hysterectomy
• If positive disease? Studies not powered to
  answer this .

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Some other studies

• Neoadjuvant Chemotherapy followed by surgery and
  other combinations.

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When is surgery not feasible/suitable?
Disease extending to the parametrium means
that surgery may be impossible, and there will be
a need for Adjuvant Chemoradiotherapy therefore
give the latter and reduce morbidity
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Disease Localised to the Cervix
Options Local Excision Loop TAH Wertheims
Hysterectomy Trachelectomy / Pelvic
Lymphadenectomy
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Stage 1A1 Squamous Carcinoma
A loop cone excision of the cervix is sufficient
treatment Once
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All invasive and preinvasive disease
excised Need to have clear margins at least 5
mm for invasive disease
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Stage 1A1 Adenocarcinoma
Problem with definition Skip lesions can
occur For lesions 3 -5 mm x 7 mm, 141 women
only 1 case of lymph node disease 0.73
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Radical Trachelectomy and Pelvic Lymphadenectomy
Used in early stage carcinoma ? Confine to women
with no children. Councelling of paramount
importance
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What is done?
One stage procedure Pelvic Lymphadenectomy and
Trachelectomy Two stage procedure Pelvic
Lymphadenectomy and if nodes negative Then
Trachelectomy
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Lymphadenectomy
Intraperitoneal Extraperitoneal Laparoscopic
As the principle is to preserve fertility
logically The intra-peritoneal approach should
be avoided.
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Cervical Cancer
Cervical Circlage
Parametrial Tissue
But will surgery be further modified? Why
parametrial tissue which are but 2 of 4 planes ?
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Trachelectomy
If the disease on histology involves the upper
limits of the specimen then hysterectomy
recommended If involves the lateral limits ?
Need surgery Would require adjuvant
radiotherapy ? Pathology assessment can be done
at trachelectomy
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Cervical Cancer
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
major indications to cease this approach in
carefully selected patients.
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Pregnancy
Pregnancy can be achieved But 25 chance of
miscarriage 30 risk of premature labour 100
risk of Caesarean Section
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Risk of Recurrence
Limited Follow up data However the known risk
of recurrence is 5 or less Covens et al.
1999 Case Control study Recurrence rate with
fertility preservation equal to that of radical
surgery 0-5
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Conclusions
Surgery in cervical cancer should be used with
the intention of cure Fertility can be
preserved Follow-up is, however,
limited Patient Selection paramount. The
experimental aspect must be stressed. Chemo-rad
iotherapy has replaced radical surgery in some
cases.