Cervical Cancer

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Cervical Cancer
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• Amita Maheshwari
• Assoc. Professor of Gynecologic Oncology
• Tata Memorial Hospital
• maheshwariamita_at_yahoo.com

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Cervical Cancer Epidemiology

• Globally cervical cancer is the second most
  cancer among women
• 5,00,000 new cases 2,75,000 deaths/year
• 10 of all cancer related deaths in women
• The most common cancer in women in India
• 1,32,000 new cases / year and
  74-100
  deaths / year
• Every 7 minutes a woman dies of cervical cancer

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Staging of cervical cancer

• FIGO (2008) Staging For Cervical Cancer
  Clinical staging using examination
  under anesthesia, standard
  basic radiology including X-ray chest.
• Value of modern radiological investigations
• CT scan- R-P lymph nodes.
• High specificity and low sensitivity.
• MRI- Equal to CT scan for R-P evaluation.
• More accurate for assessment of cervical tumor
  and surrounding tissue.
• PET scan- More accurate to detect LN metastases.

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FIGO Staging

• Stage I Carcinoma confined to cervix
• Stage IA1 Stromal invasion upto 3mm in depth
• ? 7mm in width.
• Stage IA2 Stromal invasion 3-5 mm in depth
  ? 7mm in width.
• Stage IB Clinical lesions confined to the
  cervix or
  pre-clinical lesions gtstage IA2
• Stage IB1 Lesions ? 4 cm
• Stage IB2 Lesions gt 4 cm

FIGO 2008
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FIGO Staging.

• FIGO stage Definition
• Stage IIA Involvement of upper 2/3rd of vagina
• Stage IIA1 Lesions ? 4 cm
• Stage IIA2 Lesions gt 4 cm
• Stage II B Involvement of medial parametrium
• Stage IIIA Involvement of lower 1/3rd of vagina
• Stage IIIB Involvement of para upto LPW/HN
• Stage IVA Bladder /or bowel involvement
• Stage IVB Distant metastasis

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Basic Principles of Management of Cervical Cancer

• All stages of cervical cancer can be treated by
  radiation therapy
• Concurrent chemo-radiation is superior to
  radiation alone
• FIGO stages I-IIA cervical cancer are amenable to
  primary surgical treatment
• Adjuvant Rx may be required after Sx

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Surgical Management of Ca-Cervix

• St.-IA1
• Class-I
• Simple
• Hysterectomy
• Radical
• Trachelectomy
• Radical Cone

St.-IA2 Class-II Modified Rad. Hyst.BPLND Radi
cal Trachelectomy
St.IB1 Class-III Rad. Hyst. BPLND Radical Trac
helectomy (lt 2 cm)
St.IB2/IIA Class-III Rad. Hyst. BPLND
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Extent of Surgery Five classes of hysterectomy
(Piver, 1974)

• Class Type of Surgical margins Indications
• Hysterectomy
• I Extrafascial No vagina, parametia FIGO
  stage IA1
• no ureteric mobilization without LVSI
• II Modified Mid portion of uterosacral FIGO
  stage IA2,
• Radical cardinal ligaments, IA1 with LVSI
• 1-2 cm of vagina
• III Radical All uterosacral cardinal FIGO
  stage IB-IIA
• ligaments,
• 1/3rd of vagina,

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Extent of Hysterectomy
Class-I
Class-II
Class-III
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Extent of Surgery Five classes of hysterectomy
(Piver, 1974) cont..

• Class Type of Surgical margins Indications
• Hysterectomy
• IV Radical ureter completely dissected
  Recurrent disease
• from cervico-vesical ligament
• superior vesicle art. sacrificed
• 3/4th of vagina, ,
• V Radical Resection includes portion
  Recurrent disease of distal ureter and bladder

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Pelvic LN Metastasis in Early Cervical Ca

• Stage IA1 lt0.5
• Stage IA2 8 (0-13)
• Stage IB 12-20
• Stage IIA 20-38

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Post-operative Morbidity

• Febrile morbidity
• Bladder dysfunction
• Fistulae VVF, UVF
• Ureteric stenosis
• Neuropathies
• Thrombo-embolism
• Lymphocele
• Lower limb edema
• GI complications

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Prognostic Factors Adjuvant Rx

• Lymph node metastases
• Parametrial involvement
• Positive surgical margins
• Deep stromal invasion
• Lymph-vascular space invasion (LVSI)
• Tumor size gt 4 cm

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Adjuvant Treatment after RH
Risk factors Risk category Adjuvant Rx
Nil Low Risk None
Deep stromal invasion Tumor gt4 cm LVSI ve Intermediate Risk Adjuvant pelvic RT
Lymph node ve Cut margin ve Parametrium ve High Risk Adjuvant Concurrent CT RT
any two
any one
Peters et al. J Clin Oncol.2000
Sedlis et al. Gynecol Oncol.1999
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Fertility Preserving Surgeries

• Radical resection of the primary tumor with an
  adequate clear margin /- lymphadenectomy
• Types of surgery Stage of the disease
• Conization Stage IA1 without LVSI
• Conization with BPLND Stage IA1 with LVSI
• Radical Trachelectomy with BPLND Stages IA2-IB1,
  
• IA1 with LVSI
• Trachelectomy Lymphadenectomy

Vaginal
Laparoscopic
Extra-peritoneal
Abdominal
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Radical Trachelectomy

• - Dargent et al (1994) described the technique.
• Eligibility criteria
• Desire to preserve fertility.
• Upto FIGO stages IB1( lt2cm).
• Limited endo-cervical involvement.
• No evidence of pelvic lymph node metastasis.

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Radical trachelectomy..

• Pelvic lymphadenectomy
• Frozen section
• Negative Nodes
• Radical trachelectomy
• If resection margins positive / nodes positive
• Radical hysterectomy
• Cervical circlage suture to ? the risk of
  abortion.

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Radical trachelectomy-Obstetric considerations

• Contraception for 6-12 mths.
• ?second trimester abortions, premature rupture of
  membrane, choriamnionitis, and preterm
  deliveries.
• Delivery by elective classical caesarean section.

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Radical Vaginal Trachelectomy- Global data

• Authors Total No Pregnancies No. of
  Rec. Deaths
• births
• Shepherd 95 43 26 3 1
• Dargent 96 55 36 4 3
• Covens 80 22 12 7 0
• Roy 66 37 24 2 1
• Schneider 36 07 04 1 0
• Burnett 21 03 03 1 0
• Schlaerth 12 04 04 0 0
• TOTAL 406 171 109 18(4.4) 5(1.2)

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Ovarian Preservation Transposition

• Risk of Ovarian Metastases in Early Cervical Ca
• SCC 0.5 (4/770)
• Adenocarcinoma 1.7 (2/121)
• Adeno-squamous 0 (0/99)

Sutton et al. Am J Obstet Gynecol. 1992
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Ovarian Transposition

• 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.
• 50 ovarian failure.
• Risk of occult metastasis

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Role of Sentinel Node Mapping

• First draining lymph node of an anatomical
  region
• Helps in tailoring the extent of surgery.
• Techniques Peri-tumoral injection of blue dye
  and/or radioactive tracer.
• Extensively used in melanoma, breast and vulvar
  Ca.
• Still experimental in Cervical Cancer!

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Role of minimally invasive surgery in the
management of cervical cancer

• Laparoscopic Radical Hysterectomy (LRH).
• Laparoscopic Assisted Radical Vaginal
• Hysterectomy (LARVH).
• Laparoscopic surgical staging.

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Chemo-Radiotherapy in Ca Cervix

• Combination of CT and RT is superior to RT
  alone.
• Chemotherapy Cisplatin 40mg/m2/wk X 5-6 wks
• Radiation therapy Combination of TELETHERAPY
  BRACHYTHERAPY
• TELETHERAPY (EXTERNAL BEAM RADIATION THERAPY)
• BRACHYTHERAPY (INTERNAL RADIATION)
• INTRACAVITARY LDR
• HDR
• INTERSTITIAL LDR HDR

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RECOMMENDED TOTAL RADIOTHERAPY DOSES
IJROBP 1993,1995,
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INTERSTITIAL BRACHYTHERAPY IN CERVIX

• INDICATIONS
• Extensive Parametrial Disease
• Narrow/distorted vagina
• Post-hystercetomy Recc.
• Distal Vaginal involvement
• Persistent disease after radical radiotherapy
  (EXT ICA)

Applicators Syed-Neblett Template
(LDR) Martinez Universal Perineal Interstitial
Template (MUPIT-HDR)
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Management of Ca-Cervix
ADVANCED IIB IVA IVA-IVB / REC
EARLY I-IIA
SURGERY
PALLIATION
RADICAL RADIOTHERAPY CHEMOTHERAPY
RADIOTHERAPY CHEMOTHERAPY
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Conclusions

• All stages can be treated with RT
• Concurrent CT-RT is superior to RT alone
• Surgery is the treatment of choice for
  early-stage cervical cancer.
• Adjuvant treatment is recommended in patients
  with poor prognostic factors.
• Preservation of fertility is possible in selected
  patients.