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Amita Maheshwari Assoc. Professor of Gynecologic Oncology Tata Memorial

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Presentation on theme: "Amita Maheshwari Assoc. Professor of Gynecologic Oncology Tata Memorial"— Presentation transcript:

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2 Amita Maheshwari Assoc. Professor of Gynecologic Oncology Tata Memorial

3 Globally cervical cancer is the second most cancer among women Globally cervical cancer is the second most cancer among women 5,00,000 new cases & 2,75,000 deaths/year 5,00,000 new cases & 2,75,000 deaths/year 10% of all cancer related deaths in women 10% of all cancer related deaths in women The most common cancer in women in India The most common cancer in women in India ~1,32,000 new cases / year and deaths / year ~1,32,000 new cases / year and deaths / year Every 7 minutes a woman dies of cervical cancer Every 7 minutes a woman dies of cervical cancer

4 FIGO (2008) Staging For Cervical Cancer: Clinical staging using examination under anesthesia, standard basic radiology including X-ray chest. Value of modern radiological investigations: CT scan:- R-P lymph nodes. CT scan:- R-P lymph nodes. High specificity and low sensitivity. MRI:-Equal to CT scan for R-P evaluation. MRI:-Equal to CT scan for R-P evaluation. More accurate for assessment of cervical tumor and surrounding tissue. PET scan:- More accurate to detect LN metastases. PET scan:- More accurate to detect LN metastases.

5 Stage I Carcinoma confined to cervix Stage IA1 Stromal invasion upto 3mm in depth & 7mm in width. 7mm in width. Stage IA2 Stromal invasion 3-5 mm in depth & 7mm in width. Stage IB Clinical lesions confined to the cervix or pre-clinical lesions >stage IA2 Stage IB1 Lesions 4 cm Stage IB2 Lesions > 4 cm FIGO 2008

6 FIGO stageDefinition Stage IIAInvolvement of upper 2/3 rd of vagina Stage IIA1Lesions 4 cm Stage IIA2Lesions > 4 cm Stage II BInvolvement of medial parametrium Stage IIIA Involvement of lower 1/3 rd of vagina Stage IIIBInvolvement of para upto LPW/HN Stage IVABladder &/or bowel involvement Stage IVBDistant metastasis

7 All stages of cervical cancer can be treated by radiation therapy All stages of cervical cancer can be treated by radiation therapy Concurrent chemo-radiation is superior to radiation alone Concurrent chemo-radiation is superior to radiation alone FIGO stages I-IIA cervical cancer are amenable to primary surgical treatment FIGO stages I-IIA cervical cancer are amenable to primary surgical treatment Adjuvant Rx may be required after Sx Adjuvant Rx may be required after Sx

8 St.-IA1Class-ISimpleHysterectomyRadicalTrachelectomy Radical Cone St.-IA2Class-II Modified Rad. Hyst.+BPLNDRadicalTrachelectomySt.IB1Class-III Rad. Hyst. + BPLNDRadicalTrachelectomy (< 2 cm) St.IB2/IIAClass-III Rad. Hyst. +BPLND

9 ClassType of Surgical margins Indications Hysterectomy IExtrafascial No vagina, parametia FIGO stage IA1 no ureteric mobilization without LVSI IIModified Mid portion of uterosacralFIGO stage IA2, Radical& cardinal ligaments, IA1 with LVSI 1-2 cm of vagina IIIRadicalAll uterosacral & cardinal FIGO stage IB-IIA ligaments, 1/3 rd of vagina, Extent of Surgery Five classes of hysterectomy (Piver, 1974)

10 Extent of Hysterectomy Class-II Class-III Class-I

11 ClassType of Surgical margins Indications Hysterectomy IVRadicalureter completely dissected Recurrent disease from cervico-vesical ligament superior vesicle art. sacrificed 3/4 th of vagina,, VRadical Resection includes portion Recurrent disease of distal ureter and bladder Extent of Surgery Five classes of hysterectomy (Piver, 1974) cont..

12 Stage IA1<0.5% Stage IA28% (0-13%) Stage IB12-20% Stage IIA20-38%

13 Febrile morbidity Febrile morbidity Bladder dysfunction Bladder dysfunction Fistulae – VVF, UVF Fistulae – VVF, UVF Ureteric stenosis Ureteric stenosis Neuropathies Neuropathies Thrombo-embolism Thrombo-embolism Lymphocele Lymphocele Lower limb edema Lower limb edema GI complications GI complications

14 Lymph node metastases Parametrial involvement Positive surgical margins Deep stromal invasion Lymph-vascular space invasion (LVSI) Tumor size > 4 cm

15 Adjuvant Treatment after RH Risk factorsRisk categoryAdjuvant Rx NilLow RiskNone Deep stromal invasion Tumor >4 cm LVSI +ve Intermediate RiskAdjuvant pelvic RT* Lymph node +ve Cut margin +ve Parametrium +ve High RiskAdjuvant Concurrent CT + RT ** **Peters et al. J Clin Oncol.2000 *Sedlis et al. Gynecol Oncol.1999 any two any one

16 Radical resection of the primary tumor with an adequate clear margin +/- lymphadenectomy Radical resection of the primary tumor with an adequate clear margin +/- lymphadenectomy Types of surgeryStage of the disease ConizationStage IA1 without LVSI ConizationStage IA1 without LVSI Conization with BPLNDStage IA1 with LVSI Conization with BPLNDStage IA1 with LVSI Radical Trachelectomy with BPLND Stages IA2-IB1, Radical Trachelectomy with BPLND Stages IA2-IB1, IA1 with LVSI Trachelectomy Lymphadenectomy VaginalLaparoscopicExtra-peritoneal Abdominal

17 - Dargent et al (1994) described the technique. Eligibility criteria: Desire to preserve fertility. Desire to preserve fertility. Upto FIGO stages IB1( <2cm). Upto FIGO stages IB1( <2cm). Limited endo-cervical involvement. Limited endo-cervical involvement. No evidence of pelvic lymph node metastasis. No evidence of pelvic lymph node metastasis.

18 Pelvic lymphadenectomy Pelvic lymphadenectomy Frozen section Negative Nodes Radical trachelectomy If resection margins positive / nodes positive Radical hysterectomy Cervical circlage suture to the risk of abortion.

19 Contraception for 6-12 mths. Contraception for 6-12 mths. second trimester abortions, premature rupture of membrane, choriamnionitis, and preterm deliveries. second trimester abortions, premature rupture of membrane, choriamnionitis, and preterm deliveries. Delivery by elective classical caesarean section. Delivery by elective classical caesarean section.

20 Authors Total No Pregnancies No. of Rec. Deaths births births Shepherd Dargent Covens Roy Schneider Burnett Schlaerth TOTAL (4.4%)5(1.2%)

21 Risk of Ovarian Metastases in Early Cervical Ca: SCC0.5% (4/770) SCC0.5% (4/770) Adenocarcinoma1.7% (2/121) Adenocarcinoma1.7% (2/121) Adeno-squamous 0 (0/99) Adeno-squamous 0 (0/99) Sutton et al. Am J Obstet Gynecol. 1992

22 Ovaries are detached from the uterus along with its blood supply and transposed in an area away from the radiation field, generally in the para-colic gutters abovethe pelvic brim. 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 metastasis Risk of occult metastasis

23 First draining lymph node of an anatomical region First draining lymph node of an anatomical region Helps in tailoring the extent of surgery. Helps in tailoring the extent of surgery. Techniques: Peri-tumoral injection of blue dye and/or radioactive tracer. Techniques: Peri-tumoral injection of blue dye and/or radioactive tracer. Extensively used in melanoma, breast and vulvar Ca. Extensively used in melanoma, breast and vulvar Ca. Still experimental in Cervical Cancer! Still experimental in Cervical Cancer!

24 Laparoscopic Radical Hysterectomy (LRH). Laparoscopic Assisted Radical Vaginal Hysterectomy (LARVH). Laparoscopic surgical staging.

25 Chemo-Radiotherapy in Ca Cervix Combination of CT and RT is superior to RT alone. Combination of CT and RT is superior to RT alone. Chemotherapy: Cisplatin 40mg/m2/wk X 5-6 wks Chemotherapy: Cisplatin 40mg/m2/wk X 5-6 wks Radiation therapy: Combination of TELETHERAPY & BRACHYTHERAPY Radiation therapy: Combination of TELETHERAPY & BRACHYTHERAPY TELETHERAPY (EXTERNAL BEAM RADIATION THERAPY) TELETHERAPY (EXTERNAL BEAM RADIATION THERAPY) BRACHYTHERAPY (INTERNAL RADIATION) BRACHYTHERAPY (INTERNAL RADIATION) INTRACAVITARYLDR INTRACAVITARYLDR HDR HDR INTERSTITIAL LDR HDR INTERSTITIAL LDR HDR

26 RECOMMENDED TOTAL RADIOTHERAPY DOSES RADIOTHERAPY TREATMENT TO BE COMPLETED WITHIN 8 WKS IJROBP 1993,1995, IIIB IIB IB/IIA IA TOTAL DOSE A ICRT-LDR POINT A EXT. RT PELVIS Stage

27 INTERSTITIAL BRACHYTHERAPY IN CERVIX INDICATIONS: Extensive Parametrial Disease Extensive Parametrial Disease Narrow/distorted vagina Narrow/distorted vagina Post-hystercetomy Recc. Post-hystercetomy Recc. Distal Vaginal involvement Distal Vaginal involvement Persistent disease after radical radiotherapy (EXT + ICA)Persistent disease after radical radiotherapy (EXT + ICA) Applicators: Syed-Neblett Template (LDR) Martinez Universal Perineal Interstitial Template (MUPIT-HDR)

28 Management of Ca-Cervix EARLY I-IIA EARLY I-IIA ADVANCED IIB – IVA IVA-IVB / REC ADVANCED IIB – IVA IVA-IVB / REC SURGERY RADICAL RADIOTHERAPY + CHEMOTHERAPY RADICAL RADIOTHERAPY + CHEMOTHERAPY PALLIATION RADIOTHERAPY CHEMOTHERAPY RADIOTHERAPY CHEMOTHERAPY

29 All stages can be treated with RT All stages can be treated with RT Concurrent CT-RT is superior to RT alone Concurrent CT-RT is superior to RT alone Surgery is the treatment of choice for early-stage cervical cancer. Surgery is the treatment of choice for early-stage cervical cancer. Adjuvant treatment is recommended in patients with poor prognostic factors. Adjuvant treatment is recommended in patients with poor prognostic factors. Preservation of fertility is possible in selected patients. Preservation of fertility is possible in selected patients.


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