1. In the name of God Isfahan medical school Shahnaz Aram MD

2. Recurrent cervical cancer ► Within 6 months after completion of primary therapy = persistent ► After 6 months = recurrent ► 1/3 patients experience tumor recurrence ► Symptoms depend on the site and extent of tumor ► early central pelvic recurrence  Vaginal discharge and bleeding

3. ► Widespread metastasis  malaise, loss of appetite, general symptoms ► Lateral pelvis recurrence has late manifestations ► Unilateral leg edema is due to lymphatic fibrosis after operation or radiation ► Urethral obstruction, unilateral or bilateral  decrease in kidney function, low back pain

4. Patients treated for cancer Evaluated: Every 3 months for the first year Every 4 months in second year Every 6 months in third year Yearly thereafter More frequently examination if abnormal symptom Examination consists of vaginal and cervical cytology

5. Complete physical and pelvic examination Chest X-Ray annually IVP, abdominal pelvic CT scan annually in the first 2 years with recurrence renal function test Ureter fibrosis occurs more than 5 years after radiation Blood test for scc Ag, if Ag increased  suspected recurrence

6. Pelvic recurrence Half of recurrence in pelvis Clinical assessment  CT, TVS Adenocarcinoma  distant site ( lung, suprclavicular) Chemoradiation for local pelvic recurrence and previous radiation Surgery (complication) Palliative chemotherapy

7. Treatment Depends on Depends on 1- mode of primary therapy 1- mode of primary therapy 2- site of recurrence 2- site of recurrence If in pelvis after radiation, most patients Exenteration If in pelvis after radiation, most patients Exenteration TAH is inadequate TAH is inadequate Occasional patients may be salvaged by radical hysterectomy Occasional patients may be salvaged by radical hysterectomy

8. If pelvic recurrence after surgery radiation ( External beam, vaginal ovoid ) Surgical therapy for post irradiation is limited to patients with central pelvic disease Small volume disease Urinary complications 30-50%

9. Preoperative Evaluation Patient selection Screen for metastasis Physical examination Careful palpation of lymph nodes FNA cytology if suspicious Random biopsy Supraclavicular ( not routine) CT scan of lungs if chest normal Abdominal pelvic CT (liver, para aortic ) CT directed FNA cytology

10. Exploratory laparatomy  Parametrial Biopsy ( fibrosis)  Bowel preparation  Parenteral nutrition  Prophylaxy for DVT  Surgical mortality increases with age  > 70?  Surgical mortality < 10%  Mortality due to hemorrhage, pulmonary thromboembolism, sepsis  Fistula 30-40% mortality

11. Pelvic Exenteration  Contraindicated surgery if 1- unilateral leg edema 1- unilateral leg edema 2- sciatic pain 2- sciatic pain 3- urethral obstruction 3- urethral obstruction  Exenteration if central pelvic recurrence  25% of patients are candidate for Exenteration  Exenteration is not performed for palliative  Before Exenteration metastasis must be ruled out by lymph node biopsy, frozen section, operative margin

12. Exenteration 1- anterior 1- anterior 2- posterior 2- posterior 3- total 3- total After total Exenteration  new pelvic floor After total Exenteration  new pelvic floor Left gastrioepiploic art release and omentom replacement Left gastrioepiploic art release and omentom replacement Supra levator Exentraation (if 1/3 upper is involved and frozen section of the lower pelvis is negative ) Supra levator Exentraation (if 1/3 upper is involved and frozen section of the lower pelvis is negative ) 5 year survival after Exenteration is 45-61% 5 year survival after Exenteration is 45-61%

13. Non-pelvic recurrence  Recurrence outside of the pelvis  Treated with radiation, operation, chemotherapy  Local recurrence with radiation  Resection of the metastasis is rarely done unless (local, 3-4 years after primary therapy)  General distant metastasis, no cure with local excision

14. Radiation re-treatment In suboptimal incomplete primary therapy Curative dose ( risk for bladder, rectum) Insertion multiple interstitial radiation source in local recurrence For curable patient, Exenteration is better Radiotherapy re-treatment (Palliative) Radiotherapy re-treatment in Locally metastatic lesions indicated if 1- painful bony metastasis 2- CNS lesion 3- severe urologic or vena caval obstruction

15. Chemotherapy  Palliative  For extra-pelvic metastasis  Relief of symptoms  Prolongation of life  Complete response is unusual  Chemotherapy for small cell carcinoma of cervix  Unresectable pelvic recurrence  General limited for lung metastasis  For a distant metastasis  Cisplatin = most clinical response  Duration of response is 4-6 months  2 cases more than 5 years  Chemoradiation 1- sensitized of cervical cancer cells 1- sensitized of cervical cancer cells 2- eliminate microscopic systemic metastasis 2- eliminate microscopic systemic metastasis  GOG cisplatin or cisplatin + paclitaxel

16. Prognosis After anterior Exenteration  30-60% five year survival After total Exenteration  20-4-% Mortality increase if 1- size of recurrence > 3cm 2- bladder invasion 3- positive pelvic lymph node 4-Recurrence after one year after radiation 5-Peritoneal disease Five year survival if positive lymph node = 5%