Cervical cancer surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [10]
Overview
Surgery
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.