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

OUTLINE Cervical cancer Endometrial cancer Ovarian cancer

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

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

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

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

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

Endometrial cancer “Generalist’s cancer” AND Overall outcome excellent BUT Outcome per stage worse than cervical cancer Majority of patients are staged incompletely

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

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

“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?)

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)

“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

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

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

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

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

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

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

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

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

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

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

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

Who should operate late stage ovarian cancer Worst survival = general surgeon Second = generalist gynaecologist Best outcome = gynaecological oncologist Numbers increase survival(>10)

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

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

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

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

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