Cytology After Radical Trachelectomy for Cervical Cancer

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Less Radical Surgery for Patients with
Early-Stage Cervical Cancer
Dr.Yousefi Professor Mashhad University of
Medical Sciences
Gynecologist Oncologist
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Ovarian Transposition Extent of Hysterectomy
lymph node metastasis Sentinel node
mapping radical trachelectomy
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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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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

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Extent of Hysterectomy
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
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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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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

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Post-operative Morbidity

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

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Less Radical Surgery

• Review of 1063 cases of stage IA2
• Rate of lymph node mets lt 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,
2009
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Less Radical Surgery

• In low risk disease
• Stage Ib1
• lt 2 cm
• LVSI -
• Rate of lymph node metastasis
• lt 5

Kinney WK. Gynecol Oncol 573-6, 1995
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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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Adjuvant Treatment after RH
Risk factors Risk category Adjuvant Rx
Nil Low Risk None
Deep stromal invasion Tumor gt4 cm LVSI Intermediate Risk Adjuvant pelvic RT
Lymph node Cut margin Parametrium 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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Less radical surgery

• Parametrial invasion
• Literature review of ptes with
• low-risk pathological characteristics
• Tumor size lt 2 cm
• Stromal invasion lt 10 mm
• Negative pelvic nodes
• No LVSI
• Risk of PI was 0.63 (5/799)

Stegeman et al. Gynecol Oncol 2007 105 475
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Less radical surgery

• Sentinel node mapping
• Particularly effective in small lesions (lt 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, 2005
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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 lt 2 cm
• Stromal invasion lt 50

Strnad P et al. Gynecol Oncol 2008 109 280
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Parametrial SN
Ureter
Sup. vesical artery
Obturator nerve
uterine artery
Right obturator SN
Right parametrial SN
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radical trachelectomy for cervical cancer
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The formal name of this operation is radical
vaginal trachelectomy (RVT) and also known as the
Dargent operation and radical trachelectomy.
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Trachelectomies, broadly, can be divided into the
simple and radical variants.
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A simple trachelectomy refers to the removal of
the cervix this can be considered to be a very
large conization procedure
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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

• Indications
• Women under 40
• Cancers up to Stage Ib (IIa)
• Strong desire to maintain fertility

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Over 90 carried out at St Bartholomews
Hospital 3 recurrences and 1 death 26 live
births
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What is done?
One stage procedure Pelvic Lymphadenectomy and
Trachelectomy Two stage procedure Pelvic
Lymphadenectomy and if nodes negative Then
Trachelectomy
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Lymphadenectomy
Intraperitoneal Extraperitoneal Laparoscopic
As the principle is to preserve fertility
logically The intra-peritoneal approach should
be avoided.
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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

• Dargent et al, 1994
• Cx parametrium upper vagina removed
• Pelvic lymphadenectomy
• Isthmic-vaginal anastomosis
• Isthmic cerclage

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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 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

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Pregnancy
Pregnancy can be achieved But 25 chance of
miscarriage 30 risk of premature labour 100
risk of Caesarean Section
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Early Stage Disease Preservation
of Fertility Radical Trachelectomy and
extra-peritoneal Pelvic Lymphadenectomy Shepherd
et al. 1998, 10 cases, 6 pregnancies,
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births. Darent et al 2000 47 cases, 13 births

miscarriage rate 25 Roy, 1998 30
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.
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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

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T HANK YOU