Surgical management of carcinoma cervix

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  • 1. SURGICAL MANAGEMENTOF CARCINOMA CERVIX Ashish Tripathi
  • 2. Investigation: Establishing the Dx  General physical examination including examination of supraclavicular,axillary and inguinofemoral lymph nodes.  Colposcopy  Cervicography  Cervical biopsy  Conisation  Endocervical canal curettage
  • 3. CERVICAL BIOPSY Colposcopy available : biopsy from suspicious area If not: employing iodine solution Shiller’s 0.3%, lugol’s iodine and Acetic acid. Types: – Surface biopsy – Punch biopsy – Wedge biopsy – Ring biopsy – Cone bipsy
  • 4. CONIZATION Both diagnostic and therapeutic purpose Removal of cone of the cervix which includes Squamocolumnar junction, stroma with glands and endocervical mucous membrane. Methods: Cold knife, CO₂ laser, Laser diathermy loop Indication: – Unsatisfactory colposcopic findings – Inconsistent findings – Positive endocervical curettage for CIN II and III – Biopsy shows microinvasion – to exclude gross invasive carcinoma
  • 5. Investigation Used during Cervical Cancer Staging Testing To Identify: Laboratory CBC Anaemia prior to surgery, chemotherapy or radiotherapy Urinalysis Hematuria Liver function Liver metastasis Creatinine and BUN levels Hydronephrosis
  • 6. Radiologic Chest radiograph Lung metastasis Intravenous pyelogram (IVP) Hydronephrosis CT scan (abdomen and pelvis) Lymph node metastasis, metastasis to other distant organs, and hydronephrosis MR imaging Local extracervical invasion + those for CT scan PET scan Lymph node metastasisProcedural Cystoscopy Tumor invasion into the bladder Proctoscopy Tumor invasion into the rectum Examination under anesthesia
  • 7. Investigations for management CBC, Hb Serum Urea, Creatinine LFT, RFT CXR – PA view CT, MRI, Abdomino-pelvic USG Lymphangiography Biopsy and histopathologic evidence of invasive malignancy should precede any treatment modality.
  • 8. Surgery:General Considerations patients with FIGO stage I to IIA cervical cancer Operable growth: Smaller tumors, not fixed to the pelvic wall and no distant metastasis Those who are physically able to tolerate an aggressive surgical procedure Those who wish to avoid the long-term effects of radiation therapy
  • 9.  Radio-resistant growth. Typical candidates include young patients who desire ovarian preservation. Retention of a functional, non-irradiated vagina. Women with pelvic masses, pelvic infections, chronic salpingitis, extensive bowel adhesion from previous peritonitis, endometriosis.
  • 10. Classification of extent ofoperation1. (Type I ) extrafascial hysterectomy3. (Type II) modified radical hysterectomy/ Wertheim hysterectomy5. (Type III) radical hysterectomy/ Meigs-Wertheim hysterectomy7. (Type IV) extended radical hysterectomy9. Type V operation: exenteration
  • 11. Simple Hysterectomy (Type I) Also known as an extrafascial hysterectomy or simple hysterectomy, removes the uterus and cervix, but does require excision of the parametrium or paracolpium. It is appropriately selected for benign gynaecologic pathology, preinvasive cervical disease, and stage IA1 cervical cancer.
  • 12. Modified Radical Hysterectomy (Type II) Modified radical hysterectomy removes the cervix, proximal vagina, and parametrial and paracervical tissue. This hysterectomy is well suited for tumors with 3- 5mm depths of invasion and smaller stage IB tumors.
  • 13. Radical Hysterectomy (Type III) Requires greater resection of the parametria, and excision extends to the pelvic sidewall . The ureters are completely dissected from their beds, and the bladder and rectum are mobilized to permit this more extensive removal of tissue. In addition, at least 2 to 3 cm of proximal vagina is resected. This procedure is performed for larger IB lesions, and for patients with relative contraindications to radiation such as diabetes, pelvic inflammatory disease, hypertension, collagen disease or adnexal masses.
  • 14.  Type IV - Extended radical hysterectomy – Removal of all periureteral tissue, superior vesicle artery and ¾ of vagina. – Indication: Anteriorly occurring central recurrences where preservation of bladder still possible. Type V - Exenteration – Portion of ureter and bladder are also dissected. – Indication: Central recurrent cancer involving portion of the distal ureter or bladder.
  • 15. Patient Preparation T/t and control of systemic illness like DM,HTN. PAC and consultation with anesthesiologist. Blood grouping and cross matching with adequate Mx of blood for transfusion if required. Mini-heparisation: s/c heparin 5000IU tid 8-24 hrs prior to SX. Bowel preparation. Prophylactic antibiotics. Optimal RFT, Resp.FT and LFT.
  • 16. Management of InvasiveCancer of the Cervix Stage Ia1 ≤3 mm invasion, no LVSI Conization or type I hysterectomy ≤3 mm invasion, w/LVSI Radical trachelectomy or type II radical hysterectomy with pelvic lymph node dissection la2 >3–5 mm invasion Radical trachelectomy or type II radical hysterectomy with pelvic lymphadenectomy lb1 >5 mm invasion, <2 cm Radical trachelectomy or type III radical hysterectomy with pelvic lymphadenectomy >5 mm invasion, >2 cm Type III radical hysterectomy with pelvic lymphadenectomy
  • 17. lb2 >5 mm invasion Type III radical hysterectomy with pelvic and paraaortic lymphadenectomy or primary chemoradiationStage IIa Type III radical hysterectomy with pelvic and paraaortic lymphadenectomy or primary chemoradiation IIb, IIIa, IIIb Primary chemoradiationStage IVa Primary chemoradiation or primary exenteration IVb Primary chemotherapy ±6 radiation LVSI: lymphovascular space invasion
  • 18. Complications of Radical HysterectomyAcute Complications1.Blood loss (average, 0.8 L) and shock2.Ureterovaginal fistula (1% - 2%)3.Vesicovaginal fistula (1%)4.Pulmonary thrombo-embolism (1% - 2%)5.Small bowel obstruction, ileus (1%)6.Sepsis, pelvic cellulitis (7%) and urinary tract infection (6%). Wound infection, pelvic abscess, and phlebitis in <5% of patients.7.Damage to adjacent organs
  • 19. Subacute complications Postoperative bladder dysfunction, ureteric fistula, urine retention. Lymphocyst formation.
  • 20. Chronic complications Bladder hypotonia Bladder Atony Ureteric strictures :rare
  • 21. Palliative care Radiotherapy and Chemotherapy Pain Management – Intrathecal injection of phenol – Analgesics Good nursing care Psychological and physical support Follow up
  • 22. References: Howkins & Bourne Shaw’s Textbook of Gynaecology,14th edition Novak’s Gynaecology,14th edition Williams’ Gynaecology,