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Less Radical Surgery for Patients with Early-Stage Cervical Cancer Dr.Yousefi Professor Mashhad University of Medical Sciences Gynecologist Oncologist 2www.zohrehyousefi.com

Ovarian Transposition Extent of Hysterectomy lymph node metastasis Sentinel node mapping radical trachelectomy 3www.zohrehyousefi.com

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 Ovarian Transposition 4www.zohrehyousefi.com

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Cervical cancer - treatment Radical hysterectomy, radiotherapy and chemoradiation are all radical modalities Majority of cancers detected in younger women are early stage ? too radical for early disease ? can fertility be conserved 6www.zohrehyousefi.com

Extrafascial hysterectomy; pubocervical ligament is incised, lateral deflection of the ureter CIN, early stromal invasion II- Removal of the medial half of the cardinal and uterosacral ligaments; upper third of the vagina removed Microcarcinoma postirradiation III Removal of the entire cardinal and uterosacral ligaments; upper third of the vagina removed Stages Ib and IIa lesions Extent of Hysterectomy 7www.zohrehyousefi.com

Extent of Hysterectomy Class-II Class-III Class-I 8www.zohrehyousefi.com

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.. 9www.zohrehyousefi.com

Less radical surgery Morbidity of the radical hysterectomy and nodes comes from Lymphadenectomy Lymphocele/lymphoedema, nerve/vessel injury Parametrectomy Damage to autonomic nerve fibers bladder, bowel and sexual dysfunction Late urological/rectal dysfunctions: 20-30% 10www.zohrehyousefi.com

Post-operative Morbidity  Febrile morbidity  Bladder dysfunction  Fistulae – VVF, UVF  Ureteric stenosis  Neuropathies  Thrombo-embolism  Lymphocyst  Lower limb edema  GI complications 11www.zohrehyousefi.com

Less Radical Surgery Review of 1063 cases of stage IA2 Rate of lymph node mets: < 5% 12% in ptes with LVSI + 1.3% in ptes with LVSI – Recurrence rate: 3.6% Van Meurs H et al. Int J Gynecol Cancer 19: 21, www.zohrehyousefi.com

Less Radical Surgery In low risk disease Stage Ib1 < 2 cm LVSI - Rate of lymph node metastasis: < 5% Kinney WK. Gynecol Oncol 57:3-6, www.zohrehyousefi.com

Stage IA1<0.5% Stage IA28% (0-13%) Stage IB12-20% Stage IIA20-38% Pelvic LN Metastasis in Early Cervical Ca 14www.zohrehyousefi.com

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Adjuvant Treatment after RH Risk factorsRisk categoryAdjuvant Rx NilLow RiskNone Deep stromal invasion Tumor >4 cm LVSI Intermediate Risk Adjuvant pelvic RT* Lymph node Cut margin Parametrium High RiskAdjuvant Concurrent CT + RT ** **Peters et al. J Clin Oncol.2000 *Sedlis et al. Gynecol Oncol.1999 any two any one 16www.zohrehyousefi.com

Less radical surgery Parametrial invasion Literature review of ptes with low-risk pathological characteristics: Tumor size < 2 cm Stromal invasion < 10 mm Negative pelvic nodes No LVSI Risk of PI was 0.63% (5/799) Stegeman et al. Gynecol Oncol 2007; 105: www.zohrehyousefi.com

Less radical surgery Sentinel node mapping Particularly effective in small lesions (< 2 cm) Detection rate: 100% False negative rate: 0% Could reduce the radicality/morbidity of the PLND in this low risk group Rob L et al. Gynecol Oncol 98: 281, www.zohrehyousefi.com

Less radical surgery Relationship between SN vs PI status 158 ptes IA2/IB1 If SN +: risk of PI 28% If SN - : risk of PI 0% if Tumor < 2 cm Stromal invasion < 50% Strnad P et al. Gynecol Oncol 2008; 109: www.zohrehyousefi.com

Parametrial SN Right obturator SNRight parametrial SN Ureter uterine artery Sup. vesical arteryObturator nerve 20www.zohrehyousefi.com

radical trachelectomy for cervical cancer 21www.zohrehyousefi.com

The formal name of this operation is radical vaginal trachelectomy (RVT) and also known as the Dargent operation and radical trachelectomy. 22www.zohrehyousefi.com

Trachelectomies, broadly, can be divided into the simple and radical variants. 23www.zohrehyousefi.com

A simple trachelectomy refers to the removal of the cervix; this can be considered to be a very large conization procedure conization 24www.zohrehyousefi.com

 Radical resection of the primary tumor with an adequate clear margin +/- lymphadenectomy Types of surgeryStage of the disease  ConizationStage IA1 without LVSI  Conization with BPLNDStage IA1 with LVSI  Radical Trachelectomy with BPLND Stages IA2-IB1, IA1 with LVSI Trachelectomy Lymphadenectomy Fertility Preserving Surgeries VaginalLaparosc opic Extra- peritoneal Abdominal 25www.zohrehyousefi.com

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Radical trachelectomy Indications Women under 40 Cancers up to Stage Ib (IIa) Strong desire to maintain fertility 28www.zohrehyousefi.com

Over 90 carried out at St Bartholomew’s Hospital 3 recurrences and 1 death 26 live births 29www.zohrehyousefi.com

What is done? One stage procedure Pelvic Lymphadenectomy and Trachelectomy Two stage procedure Pelvic Lymphadenectomy and if nodes negative Then Trachelectomy 30www.zohrehyousefi.com

Lymphadenectomy Intraperitoneal Extraperitoneal Laparoscopic As the principle is to preserve fertility logically The intra-peritoneal approach should be avoided. 31www.zohrehyousefi.com

Radical trachelectomy.. 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. 32www.zohrehyousefi.com

Radical trachelectomy Dargent et al, 1994 Cx + parametrium + upper vagina removed Pelvic lymphadenectomy Isthmic-vaginal anastomosis Isthmic cerclage 33www.zohrehyousefi.com

Radical trachelectomy- Obstetric considerations 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. 34www.zohrehyousefi.com

Radical trachelectomy -follow-up CYTOLOGY IS CRUCIAL IN FOLLOW-UP Isthmic-vaginal smears are taken using brush and spatula 3 monthly in first year 4 monthly in second year 6 monthly from 2-5 years annually thereafter till 10 years After 10 years, discharged and sent to NHSCSP call-recall programme 35www.zohrehyousefi.com

Pregnancy Pregnancy can be achieved But 25% chance of miscarriage 30% + risk of premature labour 100% risk of Caesarean Section 36www.zohrehyousefi.com

Early Stage Disease Preservation of Fertility Radical Trachelectomy and extra-peritoneal Pelvic Lymphadenectomy Shepherd et al. 1998, 10 cases, 6 pregnancies, 3 births. Darent et al cases, 13 births miscarriage rate 25% Roy, cases, 6 attempted pregnancy, 4 successful Follow-up is limited and numbers are small but no major indications to cease this approach in carefully selected patients. 37www.zohrehyousefi.com

Summary Trachelectomy represents conservative surgical approach for early stage invasive cervical cancer Likely to increase in popularity Cytology is mainstay of follow-up Essentially cytological features are predictable and similar to those after cone biopsy 38www.zohrehyousefi.com

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