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SURGICAL APPROACH TO GYNAECOLOGICAL CANCERS

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Radical abdominal hysterectomy with pelvic node clearance without ... Remove adnex and tumour bed completely, can retain fertility. Peritoneal staging. Omentum ... – PowerPoint PPT presentation

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Title: SURGICAL APPROACH TO GYNAECOLOGICAL CANCERS


1
SURGICAL APPROACH TO GYNAECOLOGICAL CANCERS
  • Prof Greta Dreyer
  • Head Gynaecological Oncology
  • University of Pretoria
  • South Africa

2
OUTLINE
  • Cervical cancer
  • Endometrial cancer
  • Ovarian cancer

3
Cervical cancer
  • Surgery for
  • DISEASE CONFINED TO CERVIX
  • FREELY MOBILE TUMOUR
  • Not for
  • The very old
  • The medically - or immunocompromised
  • Etc

4
Cervical cancer
  • Mainstay
  • Radical abdominal hysterectomy with pelvic node
    clearance without removal of gonads
  • (RH/ND)
  • But
  • Surgery tailored to the tumour size
  • Alternatives available

5
Long term results of RH/ND
  • Excellent survival and tumour control
  • Morbidity and survival increased by post-op
    adjuvant (chemo)radiation
  • Bladder nerve injury with
  • Inability to empty
  • Detrussor instability
  • Some vaginal disfunction
  • Classical radiation complications

6
Alternatives to RH/ND
  • Radical trachelectomy with (laparoscopic) pelvic
    nodes without removal of uterus
  • Modified radical hysterectomy with (limited)
    pelvic nodes
  • Neo-adjuvant chemotherapy followed by definitive
    surgery
  • Consider oophorectomy for (large) adenocarcinomas

7
Cervical cancer
  • SINS
  • Inappropriate non-radical hysterectomy
  • Hysterectomy without pap-test
  • Hysterectomy without specific diagnosis of
    abnormal pap test
  • Continuing to remove cervical tumour incompletely
    when stumbled upon
  • LLETZ as biopsy of visible tumour

8
Endometrial cancer
  • Generalists cancer
  • AND
  • Overall outcome excellent
  • BUT
  • Outcome per stage worse than cervical cancer
  • Majority of patients are staged incompletely

9
Endometrial cancer
  • Radiation used to salvage incomplete surgery
  • Appropriate post-operative radiation improves
    local control
  • Radiation NOT shown to improve survival

10
Endometrial cancer
  • Surgery for
  • Everyone
  • Two approaches early and late stage
  • Not for
  • Parametrial (paracervical) disease
  • Metastatic disease (outside abdomen)

11
Early stage endometrial cancer
  • Definition
  • Tumour confined to pelvic area
  • Determine risk for nodal metastases
  • Tumour grade (grade 2)
  • Tumour size (2 cm)
  • Cervical / adnexal involvement (stage 2)
  • Myometrial involvement (any)
  • High age (65?)

12
Surgical approach to early stage endometrial
cancer
  • Low risk
  • TAH BSO
  • Washings
  • ?node sampling
  • Higher risk
  • Above PLUS formal pelvic node dissection
  • Consider upper abdominal staging (clear cell and
    papillary serous)
  • Consider radical hysterectomy (cervix)

13
Late stage endometrial cancer
  • Definition
  • Tumour (probably) not confined to pelvic area /
    uterus and adnexae
  • AIMS
  • Tumour debulking as for ovarian cancer
  • Maximum information for logical adjuvant treatment

14
Surgical approach to late stage endometrial
cancer
  • Pelvic clearance
  • always possible
  • NOT if advanced parametrial disease
  • Includes removal of pelvic nodes normal and
    involved
  • Upper abdominal staging / debulking
  • Omentum
  • Visible disease
  • Para-aortic nodes

15
Results of appropriate surgery for endometrial
cancer
  • Early stage
  • Better stratification for adjuvant treatment
  • Less referral for radiation
  • Acceptable surgical morbidity
  • Late stage
  • More aggressive treatment of late stage
  • Improved outcome of late stage

16
Ovarian cancer
  • Pitfalls
  • Pre-operative evaluation
  • Surgical approach
  • Surgery for recurrent cancer

17
Pitfalls in ovarian cancer
  • Unsuspected and undiagnosed cancer
  • Unsuspected extent of disease leading to
    incomplete surgery
  • Inappropriate surgical team
  • POOR PREPARATION

18
Pre-operative evaluation
  • RMI
  • Medical status
  • Extent of disease
  • Clinical evaluation
  • Radiology
  • Tumour markers

19
RISK FOR MALIGNANCY INDEX RMI
  • Ca 125 value x
  • Ultrasound score (0-5) x
  • Menopausal status (1 or 3)

20
Complete surgery for ovarian cancer
  • Early stage ovarian cancer
  • STAGING
  • Late stage ovarian cancer
  • DEBULKING

21
Surgery for early stage ovarian cancer
  • Appropriate incision
  • Washings
  • Remove adnex and tumour bed completely, can
    retain fertility
  • Peritoneal staging
  • Omentum
  • Pelvic nodes

22
Intra-operative accurate staging of ovarian cancer
  • USOminimum tumour surgery
  • Omentectomymandatory easy
  • Peritoneal biopsiessuper easy
  • Draining l/npelvic para-aortic
  • Upper abdomen exploration inspection and
    multiple biopsies

23
Upstaging of apparent early ovarian cancer
  • USO
  • Omentectomy 20
  • Multiple pelvic peritoneal biopsies 5-10
  • Draining lymph nodes 20
  • Upper abdomen 10-15

24
Surgery for late stage ovarian cancer
  • WHO should operate??
  • Midline incision (scopic)
  • Ascites and assess operability
  • Pelvic clearance (retroperitoneal)

25
Who should operate late stage ovarian cancer
  • Worst survival general surgeon
  • Second generalist gynaecologist
  • Best outcome gynaecological oncologist
  • Numbers increase survival(gt10)

26
Surgery for late stage ovarian cancer
  • Total omentectomy
  • Appendectomy
  • Peritoneal stripping
  • Consider limited bowel resection/anastomosis
  • Consider splenectomy

27
Reasons given for suboptimal debulking
  • 15 patient factors
  • Unstable, age, medical disease
  • 2 pelvic tumour not resectable
  • 80 upper abdominal disease not resectable

28
Extent of surgery for disseminated ovarian cancer
  • High MM surgery
  • Prognosis poor if sub-optimal chemo-response
  • There is some logic in neo-adjuvant or induction
    chemotherapy

29
Conclusion
  • Pre-operative evaluation extremely important for
    all diseases
  • Radiology
  • Laboratory
  • Clinical
  • WHO should be operated
  • WHO should operate
  • HOW to operate
  • WHEN to operate

30
Conclusion
  • Increasing emphasis on stratification and expert
    surgery
  • Total radical removal of disease
  • Collecting complete staging information on
    histology
  • Adapting surgical aggressiveness to tumour and
    patient
  • Induction chemotherapy to selected patients
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