2 Assoc. Professor of Gynecologic Oncology Tata Memorial Hospital Amita MaheshwariAssoc. Professor of Gynecologic OncologyTata Memorial Hospital
3 Cervical Cancer: Epidemiology Globally cervical cancer is the second most cancer among women5,00,000 new cases & 2,75,000 deaths/year10% of all cancer related deaths in womenThe most common cancer in women in India~1,32,000 new cases / year and deaths / yearEvery 7 minutes a woman dies of cervical cancer
4 Staging of cervical cancer 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.High specificity and low sensitivity.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.
5 FIGO StagingStage I Carcinoma confined to cervix Stage IA1 Stromal invasion upto 3mm in depth & 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 cmFIGO 2008
6 FIGO Staging…. FIGO stage Definition Stage IIA Involvement of upper 2/3rd of vaginaStage IIA1 Lesions 4 cmStage IIA2 Lesions > 4 cmStage II B Involvement of medial parametriumStage IIIA Involvement of lower 1/3rd of vaginaStage IIIB Involvement of para upto LPW/HNStage IVA Bladder &/or bowel involvementStage IVB Distant metastasis
7 Basic Principles of Management of Cervical Cancer All stages of cervical cancer can be treated by radiation therapyConcurrent chemo-radiation is superior to radiation aloneFIGO stages I-IIA cervical cancer are amenable to primary surgical treatmentAdjuvant Rx may be required after Sx
9 Five classes of hysterectomy (Piver, 1974) Extent of SurgeryFive classes of hysterectomy (Piver, 1974)Class Type of Surgical margins IndicationsHysterectomyI Extrafascial No vagina, parametia FIGO stage IA1no ureteric mobilization without LVSIII Modified Mid portion of uterosacral FIGO stage IA2,Radical & cardinal ligaments, IA1 with LVSI1-2 cm of vaginaIII Radical All uterosacral & cardinal FIGO stage IB-IIAligaments,1/3rd of vagina,
10 Extent of Hysterectomy Class-IClass-IIClass-III
11 Five classes of hysterectomy (Piver, 1974) cont.. Extent of SurgeryFive classes of hysterectomy (Piver, 1974) cont..Class Type of Surgical margins IndicationsHysterectomyIV Radical ureter completely dissected Recurrent diseasefrom cervico-vesical ligamentsuperior vesicle art. sacrificed3/4th of vagina, ,V Radical Resection includes portion Recurrent disease of distal ureter and bladder
12 Pelvic LN Metastasis in Early Cervical Ca Stage IA1 <0.5% Stage IA2 8% (0-13%) Stage IB 12-20% Stage IIA 20-38%
16 Fertility Preserving Surgeries Radical resection of the primary tumor with an adequate clear margin +/- lymphadenectomyTypes of surgery Stage of the diseaseConization Stage IA1 without LVSIConization with BPLND Stage IA1 with LVSIRadical Trachelectomy with BPLND Stages IA2-IB1,IA1 with LVSITrachelectomy LymphadenectomyVaginalAbdominalLaparoscopicExtra-peritoneal
17 Radical Trachelectomy - Dargent et al (1994) described the technique.Eligibility criteria:Desire to preserve fertility.Upto FIGO stages IB1( <2cm).Limited endo-cervical involvement.No evidence of pelvic lymph node metastasis.
18 Radical trachelectomy.. Pelvic lymphadenectomyFrozen sectionNegative NodesRadical trachelectomyIf resection margins positive / nodes positiveRadical hysterectomyCervical circlage suture to ↓ the risk of abortion.
19 Radical trachelectomy- Obstetric considerations Contraception for 6-12 mths.↑second trimester abortions, premature rupture of membrane, choriamnionitis, and preterm deliveries.Delivery by elective classical caesarean section.
20 Radical Vaginal Trachelectomy- Global data Authors Total No Pregnancies No. of Rec. Deaths births Shepherd Dargent Covens Roy Schneider Burnett Schlaerth TOTAL (4.4%) 5(1.2%)
21 Ovarian Preservation & Transposition Risk of Ovarian Metastases in Early Cervical Ca:SCC % (4/770)Adenocarcinoma 1.7% (2/121)Adeno-squamous (0/99)Sutton et al. Am J Obstet Gynecol. 1992
22 Ovarian Transposition Ovaries are detached from the uterus along with itsblood supply and transposed in an area away from theradiation field, generally in the para-colic guttersabovethe pelvic brim.Drawbacks of Ovarian Transposition:-25% risk of benign ovarian cysts.50% ovarian failure.Risk of occult metastasis
23 Role of Sentinel Node Mapping First draining lymph node of an anatomical regionHelps in tailoring the extent of surgery.Techniques: Peri-tumoral injection of blue dye and/or radioactive tracer.Extensively used in melanoma, breast and vulvar Ca.Still experimental in Cervical Cancer!
24 Role of minimally invasive surgery in the management of cervical cancer Laparoscopic Radical Hysterectomy (LRH).Laparoscopic Assisted Radical VaginalHysterectomy (LARVH).Laparoscopic surgical staging.
25 Chemo-Radiotherapy in Ca Cervix Combination of CT and RT is superior to RT alone.Chemotherapy: Cisplatin 40mg/m2/wk X 5-6 wksRadiation therapy: Combination of TELETHERAPY & BRACHYTHERAPYTELETHERAPY (EXTERNAL BEAM RADIATION THERAPY)BRACHYTHERAPY (INTERNAL RADIATION)INTRACAVITARY LDRHDRINTERSTITIAL LDR HDR
26 RECOMMENDED TOTAL RADIOTHERAPY DOSES 85-9035-4050IIIB8545-50IIB75-8030-3545IB/IIA50-60IATOTAL DOSE ‘A’ICRT-LDRPOINT ‘A’EXT. RTPELVISStageRADIOTHERAPY TREATMENT TO BE COMPLETED WITHIN 8 WKSIJROBP 1993,1995,
29 Conclusions All stages can be treated with RT Concurrent CT-RT is superior to RT aloneSurgery is the treatment of choice for early-stage cervical cancer.Adjuvant treatment is recommended in patients with poor prognostic factors.Preservation of fertility is possible in selected patients.