Cervical cancer surgery: Difference between revisions
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==Surgery== | ==Surgery== | ||
===In Situ Cervical Cancer=== | |||
:*Conization | |||
When the endocervical canal is involved, laser or cold-knife conization may be used for selected patients to preserve the uterus, avoid radiation therapy, and more extensive surgery. | |||
In selected cases, the outpatient LEEP may be an acceptable alternative to cold-knife conization. This procedure requires only local anesthesia and obviates the risks associated with general anesthesia for cold-knife conization. However, controversy exists about the adequacy of LEEP as a replacement for conization; LEEP is unlikely to be sufficient for patients with adenocarcinoma in situ. | |||
:* Hysterectomy for postreproductive patients | |||
Hysterectomy is standard therapy for women with cervical adenocarcinoma in situ, because of the location of the disease in the endocervical canal and the possibility for skip lesions in this region, making margin status a less reliable prognostic factor. However, the effect of hysterectomy compared with conservative surgical measures on mortality has not been studied. Hysterectomy may be performed for squamous cell carcinoma in situ if conization is not possible because of previous surgery, or if positive margins are noted after conization therapy. Hysterectomy is not an acceptable front-line therapy for squamous carcinoma in situ. | |||
===Stage IA Cervical Cancer=== | |||
*Standard treatment options for stage IA1 cervical cancer include the following: | |||
:*Conization | |||
If the depth of invasion is less than 3 mm, no vascular or lymphatic channel invasion is noted, and the margins of the cone are negative, conization alone may be appropriate in patients who wish to preserve fertility. | |||
:* Total hysterectomy | |||
If the depth of invasion is less than 3 mm, which is proven by cone biopsy with clear margins, no vascular or lymphatic channel invasion is noted, and the frequency of lymph-node involvement is sufficiently low, lymph-node dissection at the time of hysterectomy is not required. Oophorectomy is optional and should be deferred for younger women. | |||
*Standard Treatment Options for Stage IA2 Cervical Cancer | |||
:*Modified radical hysterectomy with lymphadenectomy | |||
For patients with tumor invasion between 3 mm and 5 mm, modified radical hysterectomy with pelvic-node dissection has been recommended because of a reported risk of lymph-node metastasis of as much as 10%.Radical hysterectomy with node dissection may also be considered for patients for whom the depth of tumor invasion was uncertain because of invasive tumor at the cone margins. | |||
Other Treatment Options | |||
:*Radical trachelectomy | |||
Patients with stages IA2 to IB disease who desire future fertility may be candidates for radical trachelectomy. In this procedure, the cervix and lateral parametrial tissues are removed, and the uterine body and ovaries are maintained. | |||
Most centers utilize the following criteria for patient selection: | |||
::*Desire for future pregnancy. | |||
::*Age younger than 40 years. | |||
::*Presumed stage IA2 to IB1 disease and a lesion size no greater than 2 cm. | |||
::*Preoperative magnetic resonance imaging that shows a margin from the most distal edge of the tumor to the lower uterine segment. | |||
::*Squamous, adenosquamous, or adenocarcinoma cell types. | |||
Intraoperatively, the patient is assessed in a manner similar to a radical hysterectomy; the procedure is aborted if more advanced disease than expected is encountered. The margins of the specimen are also assessed at the time of surgery, and a radical hysterectomy is performed if inadequate margins are obtained.[3-7] | |||
===Hysterectomy=== | ===Hysterectomy=== | ||
Revision as of 02:45, 25 August 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [10]
Surgery
In Situ Cervical Cancer
- Conization
When the endocervical canal is involved, laser or cold-knife conization may be used for selected patients to preserve the uterus, avoid radiation therapy, and more extensive surgery. In selected cases, the outpatient LEEP may be an acceptable alternative to cold-knife conization. This procedure requires only local anesthesia and obviates the risks associated with general anesthesia for cold-knife conization. However, controversy exists about the adequacy of LEEP as a replacement for conization; LEEP is unlikely to be sufficient for patients with adenocarcinoma in situ.
- Hysterectomy for postreproductive patients
Hysterectomy is standard therapy for women with cervical adenocarcinoma in situ, because of the location of the disease in the endocervical canal and the possibility for skip lesions in this region, making margin status a less reliable prognostic factor. However, the effect of hysterectomy compared with conservative surgical measures on mortality has not been studied. Hysterectomy may be performed for squamous cell carcinoma in situ if conization is not possible because of previous surgery, or if positive margins are noted after conization therapy. Hysterectomy is not an acceptable front-line therapy for squamous carcinoma in situ.
Stage IA Cervical Cancer
- Standard treatment options for stage IA1 cervical cancer include the following:
- Conization
If the depth of invasion is less than 3 mm, no vascular or lymphatic channel invasion is noted, and the margins of the cone are negative, conization alone may be appropriate in patients who wish to preserve fertility.
- Total hysterectomy
If the depth of invasion is less than 3 mm, which is proven by cone biopsy with clear margins, no vascular or lymphatic channel invasion is noted, and the frequency of lymph-node involvement is sufficiently low, lymph-node dissection at the time of hysterectomy is not required. Oophorectomy is optional and should be deferred for younger women.
- Standard Treatment Options for Stage IA2 Cervical Cancer
- Modified radical hysterectomy with lymphadenectomy
For patients with tumor invasion between 3 mm and 5 mm, modified radical hysterectomy with pelvic-node dissection has been recommended because of a reported risk of lymph-node metastasis of as much as 10%.Radical hysterectomy with node dissection may also be considered for patients for whom the depth of tumor invasion was uncertain because of invasive tumor at the cone margins.
Other Treatment Options
- Radical trachelectomy
Patients with stages IA2 to IB disease who desire future fertility may be candidates for radical trachelectomy. In this procedure, the cervix and lateral parametrial tissues are removed, and the uterine body and ovaries are maintained. Most centers utilize the following criteria for patient selection:
- Desire for future pregnancy.
- Age younger than 40 years.
- Presumed stage IA2 to IB1 disease and a lesion size no greater than 2 cm.
- Preoperative magnetic resonance imaging that shows a margin from the most distal edge of the tumor to the lower uterine segment.
- Squamous, adenosquamous, or adenocarcinoma cell types.
Intraoperatively, the patient is assessed in a manner similar to a radical hysterectomy; the procedure is aborted if more advanced disease than expected is encountered. The margins of the specimen are also assessed at the time of surgery, and a radical hysterectomy is performed if inadequate margins are obtained.[3-7]
Hysterectomy
Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP) or cone biopsy.
Trachelectomy
- If a cone biopsy does not produce clear margins,[1] one more possible treatment option for patients who want to preserve their fertility is a trachelectomy.[2]
- This attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy.
- It is a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered a standard of care,[3] as few doctors are skilled in this procedure.
- Even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown.
- If the surgeon is not able to microscopically confirm clear margins of cervical tissue once the patient is under general anesthesia in the operating room, a hysterectomy may still be needed. This can only be done during the same operation if the patient has given prior consent.
- Due to the possible risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the womb for pathologic evaluation.
Radical Trachelectomy
A radical trachelectomy can be performed abdominally[4] or vaginally[5] and there are conflicting opinions as to which is better.[6] A radical abdominal trachelectomy with lymphadenectomy usually only requires a two to three day hospital stay, and most women recover very quickly (approximately six weeks). Complications are uncommon, although women who are able to conceive after surgery are susceptible to preterm labor and possible late miscarriage.[7] It is generally recommended to wait at least one year before attempting to become pregnant after surgery.[8] Recurrence in the residual cervix is very rare if the cancer has been cleared with the trachelectomy.[9] Yet, it is recommended for patients to practice vigilant prevention and follow up care including pap screenings/colposcopy, with biopsies of the remaining lower uterine segment as needed (every 3-4 months for at least 5 years) to monitor for any recurrence in addition to minimizing any new exposures to HPV through safe sex practices until one is actively trying to conceive.
Radical Hysterectomy
Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and brachytherapy (internal radiation). Patients treated with surgery who have high risk features found on pathologic examination are given radiation therapy with or without chemotherapy in order to reduce the risk of relapse.