Surgical Intervention In Gynaecological Cancer

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General laecture on place of surgery in gynaecological cancer management.

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Surgical Intervention In Gynaecological Cancer

  1. 1. Surgical Intervention in Gynaecological Cancer Alex J Crandon MB BS PhD FRCOG FRANZCOG CGO Gynaecological Oncology Surgeon Brisbane Private Hospital/Mater Hospital Director Qld Centre for Gynaecological Cancer
  2. 2. Management of Cancer <ul><li>Make the diagnosis, </li></ul><ul><li>Determine the distribution of disease, </li></ul><ul><li>Ask: “What is the aim of treatment?” </li></ul><ul><ul><li>Cure or palliation </li></ul></ul><ul><li>What does the literature is/are the best treatment option(s). </li></ul>
  3. 3. Treatment Options <ul><li>Surgery </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Radiotherapy </li></ul><ul><li>Some combination of above </li></ul><ul><li>Doing nothing – the hardest option. </li></ul>
  4. 4. Getting it Right Determinants of survival <ul><ul><li>Site </li></ul></ul><ul><ul><li>Stage </li></ul></ul><ul><ul><li>Tumour type </li></ul></ul><ul><ul><li>Tumour differentiation </li></ul></ul><ul><ul><li>Patient’s age </li></ul></ul><ul><ul><li>Co-morbidities </li></ul></ul><ul><ul><li>Management </li></ul></ul>
  5. 5. Endometrial Cancer <ul><li>Surgery is the primary treatment modality </li></ul><ul><li>Abdominal total hysterectomy & bilateral salpingo-oophorectomy </li></ul><ul><li>Place of lymphadenectomy is still controversial </li></ul><ul><li>Some patients require adjuvant therapy </li></ul>
  6. 6. <ul><li>Typical patient </li></ul><ul><ul><li>Elderly </li></ul></ul><ul><ul><li>Obese </li></ul></ul><ul><ul><li>Hypertensive </li></ul></ul><ul><ul><li>Diabetic </li></ul></ul><ul><ul><li>Postmenopausal </li></ul></ul><ul><ul><li>Decreased mobility </li></ul></ul><ul><li>Challenges </li></ul><ul><ul><li>Surgical access </li></ul></ul><ul><ul><li>Wound infection </li></ul></ul><ul><ul><li>Wound dehiscence </li></ul></ul><ul><ul><li>Venous thombo-embolism </li></ul></ul><ul><ul><li>Pressure areas </li></ul></ul><ul><ul><li>Anaesthetic complications </li></ul></ul>Endometrial Cancer
  7. 7. LACE Trial <ul><li>Laparoscopic Approach in Cancer of the Endometrium </li></ul><ul><ul><li>TLH & BSO +/- lymphadenectomy </li></ul></ul><ul><ul><ul><li>Easier surgical access </li></ul></ul></ul><ul><ul><ul><li>Shorter in-patient stay </li></ul></ul></ul><ul><ul><ul><li>Less wound infections </li></ul></ul></ul><ul><ul><ul><li>Less problems with diabetes </li></ul></ul></ul><ul><ul><ul><li>Ambulation increased </li></ul></ul></ul>
  8. 8. Cervical Cancer Role of surgery <ul><li>Diagnosis </li></ul><ul><ul><li>Biopsy – punch, wedge, cone </li></ul></ul><ul><li>Surgical staging </li></ul><ul><ul><li>Better evaluation of disease </li></ul></ul><ul><ul><li>Effect on survival not established </li></ul></ul><ul><li>Primary treatment </li></ul><ul><li>Salvage treatment </li></ul>
  9. 9. Cervical Cancer Evaluation <ul><li>Formal FIGO staging procedure </li></ul><ul><ul><li>Examination under anaesthesia </li></ul></ul><ul><ul><li>Adequate tissue sample (biopsy) </li></ul></ul><ul><ul><li>Cystoscopy </li></ul></ul><ul><ul><li>Occasionally proctoscopy/sigmoidoscopy </li></ul></ul>
  10. 10. Cervical Cancer <ul><li>Primary treatment depends on multiple factors </li></ul><ul><ul><li>Stage of disease </li></ul></ul><ul><ul><li>Age & parity of patient </li></ul></ul><ul><ul><li>General health </li></ul></ul><ul><li>Early stage disease – 1a1 to 1b1 by primary surgery </li></ul><ul><li>Later stage disease – 1b2 to 3b by chemo-radiation </li></ul><ul><li>Stage 4 needs to be individualised </li></ul>
  11. 11. Cervical Cancer – Stage 1a <ul><li>Stage 1a1 – invasion ≤3mm deep & ≤ 7mm laterally </li></ul><ul><li>Treatment options </li></ul><ul><ul><li>Conisation </li></ul></ul><ul><ul><li>Total hysterectomy </li></ul></ul><ul><ul><li>Ovarian conservation in young patients </li></ul></ul><ul><li>Stage 1a2 – invasion >3 ≤5 mm deep & ≤7mm horizontally </li></ul><ul><li>Treatment options </li></ul><ul><ul><li>Conisation </li></ul></ul><ul><ul><li>Total hysterectomy </li></ul></ul><ul><ul><li>Ovarian conservation in young patients </li></ul></ul><ul><ul><li>Lymphadenectomy if LVSI +ve </li></ul></ul>
  12. 12. Cervical Cancer - Stage 1b <ul><li>Stage 1b1 – visible lesion ≤ 4cm confined to cervix </li></ul><ul><li>Treatment options </li></ul><ul><ul><li>Radical hysterectomy + lymphadenectomy </li></ul></ul><ul><ul><li>Chemo-radiation </li></ul></ul><ul><li>Special cases </li></ul><ul><ul><li>Radical trachelectomy </li></ul></ul><ul><li>Stage 1b2 – Visible lesion >4cm confined to cervix </li></ul><ul><li>Treatment options </li></ul><ul><ul><li>Chemo-radiation </li></ul></ul>
  13. 13. Cervical Cancer Surgery for recurrence <ul><li>Attempted salvage back to cure </li></ul><ul><ul><li>Pelvic exenteration in highly selected patients </li></ul></ul><ul><li>Palliative </li></ul><ul><ul><li>Management of simple or complex fistulas </li></ul></ul><ul><ul><li>Defunctioning stomas </li></ul></ul><ul><ul><li>Colpocliesis </li></ul></ul>
  14. 14. Cervical Cancer with Ureteric Obstruction <ul><li>In primary untreated disease </li></ul><ul><ul><li>Ascending ureteric stents </li></ul></ul><ul><ul><li>Try to avoid percutaneous nephrostomy </li></ul></ul><ul><li>In recurrent disease </li></ul><ul><ul><li>Maybe attempt ascending stents </li></ul></ul><ul><ul><li>Never use percutaneous nephrostomy </li></ul></ul>
  15. 15. Cervical Cancer Psychosocial Issues <ul><li>Vaginal shortening – 4 -100% </li></ul><ul><li>Decreased vaginal lubrication – 17 – 58% </li></ul><ul><li>Marital attrition is increased </li></ul><ul><ul><li>May uncover many dysfunctional relationships </li></ul></ul><ul><ul><li>Insufficient support services </li></ul></ul>
  16. 16. Ovarian Cancer <ul><li>Most present with advanced disease </li></ul><ul><ul><li>75-80% have stage 3-4 disease at presentation </li></ul></ul><ul><li>Surgery is the primary form of treatment followed by chemotherapy </li></ul><ul><li>Cytoreduction is of paramount importance </li></ul>
  17. 17. Stage IIIC EOC Residual Disease –v- Disease Specific Survival
  18. 18. Stage IIIC EOC Residual Disease and Relapse Free Survival
  19. 19. Conclusions <ul><li>Nil residuum have a statistically significantly better overall and relapse free 5 year survival, p<0.001 </li></ul><ul><li>Once the residuum gets to ≥1cm then it doesn’t matter how much residuum you leave behind </li></ul><ul><li>The proportion left with nil residuum needs to be increased </li></ul>
  20. 20. Management of Advanced Disease <ul><li>Pelvic & omental disease well managed </li></ul><ul><li>Tendency to leave paracolic, abdominal wall, sub-diaphragmatic, retro-hepatic and para-splenic disease to be dealt with by chemotherapy </li></ul><ul><li>This last decision is obviously detrimental to patient survival </li></ul>
  21. 21. Peritonectomy Methodology <ul><li>Very careful selection of patients for this procedure </li></ul><ul><ul><li>Relatively fit and well </li></ul></ul><ul><ul><li>Three day pre-operative inpatient assessment by anaesthetist, intensivist, medical oncologist & surgeon </li></ul></ul><ul><ul><li>Reservations involving 2 or more and the patient doesn’t get done </li></ul></ul>
  22. 22. Peritonectomy Admission <ul><li>Admitted at least 1 day prior to surgery </li></ul><ul><li>High nitrogen low residue diet continued (started at home) </li></ul><ul><li>Full bowel prep with IV infusion running </li></ul><ul><li>Repeat FBC, Biochem & LFT’s, Magnesium </li></ul><ul><li>Possible stoma sites marked </li></ul>
  23. 23. Peritonectomy Positioning
  24. 24. Peritonectomy Methodology <ul><li>Long midline incision – assess and decide if proceed to peritonectomy </li></ul><ul><li>Total omentectomy up to spleen and splenic flexure +/- splenectomy </li></ul><ul><li>Excise falciform ligament and ligamentum teres, mobilise liver and do right upper quadrant; left upper quadrant; abdominal wall and paracolic gutters; pelvis with retrograde hysterectomy, BSO, pelvic peritonectomy +/- low restorative rectal resection; finish mesentry & small bowel. </li></ul><ul><li>Insertion naso-jejunal feeding tube </li></ul><ul><li>All surgery performed by QCGC staff </li></ul>
  25. 25. Peritonectomy Extent of Surgery <ul><li>10 thoracotomies – 6 ICC’s </li></ul><ul><li>8 significant diaphragmatic resections </li></ul><ul><li>7 subsegmental liver resections </li></ul><ul><li>3 cholecystectomies </li></ul><ul><li>6 splenectomies, 2 distal pancreatectomies </li></ul><ul><li>3 partial cystectomies, 1 ureteric implantation </li></ul><ul><li>6 GIT resections; 4 small, 4 large & 1 partial antrectomy </li></ul><ul><li>5 HIPC, 4 post operative IPC. </li></ul>
  26. 26. Post Operative Management <ul><li>All patients admitted to ICU ventilated </li></ul><ul><li>Ventilatory support for 3 to 8 days </li></ul><ul><li>ICU stay for 5 to 10 days </li></ul><ul><li>Post-operative hospital stay 16 to 45 days </li></ul><ul><li>Naso-jejunal feeding started soon after admission to ICU </li></ul>
  27. 27. Lessons Learnt <ul><li>Requires a real team approach </li></ul><ul><li>Advantages in having an anaesthetist with cardiac/hepatobiliary experience </li></ul><ul><li>Extent of peritonectomy dependent on disease distribution & prior chemotherapy </li></ul><ul><li>Liver mobilisation often uncovers covert disease </li></ul><ul><li>Temperature control can be a problem – use an air mattress circulating warm air </li></ul>
  28. 28. Conclusion 1 from Peritonectomies <ul><li>Peritonectomy is a relatively safe procedure </li></ul>
  29. 29. Conclusion 2 from Peritonectomies <ul><li>If disease can be debulked to 2cm then it can be debulked to nil residuum but however long it takes to get to 2cm it will take 1 to 2 times as long again to get to nil residuum. </li></ul>
  30. 30. Conclusion 3 from Peritonectomies <ul><li>At laparotomy if initial assessment indicates that disease cannot be debulked to nil residuum then limited omentectomy only should be performed with a view to interval debulking if good response to Chemo </li></ul><ul><li>On present experience modified peritonectomy is a feasible and viable procedure for advanced EO & PP carcinoma and should become the standard of care </li></ul>
  31. 31. Following Peritonectomy <ul><li>Adjuvant chemotherapy </li></ul><ul><li>Follow-up </li></ul><ul><li>QOL takes months to recover </li></ul><ul><li>Psychosocial support is important after such ultra-radical surgery </li></ul>
  32. 32. Vulval Cancer Clinical Features <ul><li>Vulval lump or mass </li></ul><ul><li>Often long history of pruritis </li></ul><ul><li>Increasing incidence of warty carcinomas </li></ul><ul><li>Also assess vagina and cervix – common sites for HPV related disease </li></ul>
  33. 33. Vulval Cancer Place of surgery <ul><li>Diagnosis </li></ul><ul><ul><li>Wedge biopsy or good core biopsy </li></ul></ul><ul><li>Primary Treatment </li></ul><ul><ul><li>Primary vulval site </li></ul></ul><ul><ul><li>Regional nodal disease </li></ul></ul><ul><ul><li>Reconstructive </li></ul></ul><ul><ul><ul><li>Important for body image </li></ul></ul></ul><ul><ul><ul><li>Improves post-operative outcome </li></ul></ul></ul><ul><ul><ul><li>Better functional outcome </li></ul></ul></ul>
  34. 34. Vulval Cancer Old Radical Vulvectomy <ul><li>Challenges </li></ul><ul><ul><li>Provide adequate surgical excision without excessive morbidity </li></ul></ul>
  35. 35. Vulval Cancer New Approach <ul><li>Wide local excision </li></ul><ul><ul><li>Provide minimum of 10mm clear margin in fixed specimen </li></ul></ul><ul><ul><li>Remove to depth of deep fascia </li></ul></ul><ul><ul><li>Node treatment if invasion >1mm </li></ul></ul><ul><li>Separate groin node management </li></ul><ul><ul><li>Sentinel node identification </li></ul></ul><ul><ul><li>Groin node dissection </li></ul></ul>
  36. 36. Vulvectomy Nursing Care <ul><li>Easily becomes infected </li></ul><ul><li>Bed rest for 3 to 5 days to allow for healing </li></ul><ul><li>Twice daily perineal toilet and keep dry for first 5 days </li></ul><ul><li>IDC to until ambulant and healing established </li></ul>
  37. 37. Vulvectomy Complications <ul><li>Early </li></ul><ul><ul><li>Wound infection & breakdown </li></ul></ul><ul><ul><li>Urinary tract infection </li></ul></ul><ul><ul><li>DVT/PE </li></ul></ul><ul><ul><li>Seroma/cellulitis especially of groin </li></ul></ul><ul><li>Late </li></ul><ul><ul><li>Chronic leg lymphoedema </li></ul></ul><ul><ul><li>Recurrent lymphangitis </li></ul></ul><ul><ul><li>Stress incontinence </li></ul></ul><ul><ul><li>Prolapse </li></ul></ul><ul><ul><li>Introital stenosis </li></ul></ul><ul><ul><li>Osteomyelitis </li></ul></ul><ul><ul><li>Fistula </li></ul></ul>
  38. 38. Vaginal Cancer <ul><li>Surgery usually limited to establishing the diagnosis. </li></ul><ul><li>Generally treated by radiotherapy +/- chemotherapy </li></ul>
  39. 39. Palliative Surgery <ul><li>GIT obstruction </li></ul><ul><ul><li>Stoma formation </li></ul></ul><ul><li>Ureteric obstruction </li></ul><ul><ul><li>Don’t rush into percutaneous ureterostomy </li></ul></ul><ul><li>Fistula formation </li></ul><ul><ul><li>Genital tract (vesico-vaginal / entero-vaginal) </li></ul></ul><ul><ul><li>Entero-cutaneous </li></ul></ul>

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