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 “Generalist’s 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
USO=minimum tumour surgery
Omentectomy=mandatory & easy
Peritoneal biopsies=super easy
Draining l/n=pelvic & para-aortic
Upper abdomen exploration = inspection and multiple biopsies

23. Upstaging of apparent early ovarian cancer
USO
Omentectomy 20%
Multiple pelvic peritoneal biopsies %
Draining lymph nodes 20%
Upper abdomen %

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(>10)

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 M&M 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