Amita MaheshwariAmita MaheshwariAssoc. Professor of Gynecologic

OncologyTata Memorial Hospital

maheshwariamita@yahoo.commaheshwariamita@yahoo.com

Globally cervical cancer is the second most Globally cervical cancer is the second most cancer among women cancer among women 5,00,000 new cases & 2,75,000 deaths/year5,00,000 new cases & 2,75,000 deaths/year 10% of all cancer related deaths in women10% of all cancer related deaths in women

The most common cancer in women in IndiaThe most common cancer in women in India ~1,32,000 new cases / year and ~1,32,000 new cases / year and

74-100 deaths / year 74-100 deaths / year

Every 7 minutes a woman dies of cervical Every 7 minutes a woman dies of cervical cancercancer

FIGO (2008) Staging For Cervical Cancer:FIGO (2008) Staging For Cervical Cancer:

Clinical staging using examination under anesthesia, Clinical staging using examination under anesthesia,

standard basic radiology including X-ray chest. standard basic radiology including X-ray chest.

Value of modern radiological investigations:Value of modern radiological investigations: CT scan:-CT scan:- R-P lymph nodes.R-P lymph nodes.

High specificity and low sensitivity.High specificity and low sensitivity. MRI:-MRI:- Equal to CT scan for R-P evaluation.Equal to CT scan for R-P evaluation.

More accurate for assessment of cervical More accurate for assessment of cervical tumor tumor and surrounding tissue.and surrounding tissue.

PET scan:-PET scan:- More accurate to detect LN metastases. More accurate to detect LN metastases.

Stage IStage I Carcinoma confined to cervix Carcinoma confined to cervix

Stage IA1Stage IA1 Stromal invasion upto 3mm in depth Stromal invasion upto 3mm in depth & &

7mm in width.7mm in width.

Stage IA2Stage IA2 Stromal invasion 3-5 mm in depth & Stromal invasion 3-5 mm in depth & 7mm in width. 7mm in width.

Stage IBStage IB Clinical lesions confined to the cervix Clinical lesions confined to the cervix or pre-clinical lesions >stage IA2 or pre-clinical lesions >stage IA2

Stage IB1Stage IB1 Lesions Lesions 4 cm 4 cm

Stage IB2Stage IB2 Lesions > 4 cm Lesions > 4 cm FIGO 2008

FIGO stage Definition

Stage IIA Involvement of upper 2/3rd of vagina

Stage IIA1 Lesions 4 cm

Stage IIA2 Lesions > 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

All stages of cervical cancer can be All stages of cervical cancer can be treated by radiation therapytreated by radiation therapy

Concurrent chemo-radiation is superior Concurrent chemo-radiation is superior to radiation aloneto radiation alone

FIGO stages I-IIA cervical cancer are FIGO stages I-IIA cervical cancer are amenable to primary surgical treatmentamenable to primary surgical treatment

Adjuvant Rx may be required after SxAdjuvant Rx may be required after Sx

St.-IA1St.-IA1

Class-IClass-ISimpleSimpleHysterectomyHysterectomy

RadicalRadicalTrachelectomTrachelectom

yy

Radical ConeRadical Cone

St.-IA2 St.-IA2

Class-IIClass-II

Modified Modified Rad.Rad.

Hyst.Hyst.+BPLND+BPLND

RadicalRadical

TrachelectomTrachelectomyy

St.IB1St.IB1

Class-IIIClass-III

Rad. Hyst. +Rad. Hyst. +

BPLNDBPLND

RadicalRadical

TrachelectomTrachelectomyy

(< 2 cm)(< 2 cm)

St.IB2/IIASt.IB2/IIA

Class-IIIClass-III

Rad. Hyst. Rad. Hyst. +BPLND+BPLND

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,

Extent of SurgeryExtent of SurgeryFive classes of hysterectomy (Piver, Five classes of hysterectomy (Piver,

1974)1974)

Extent of Hysterectomy

Class-II

Class-III

Class-I

ClassClass Type of Type of Surgical margins Surgical margins IndicationsIndicationsHysterectomyHysterectomy

IVIV RadicalRadical ureter completely dissected ureter completely dissected Recurrent diseaseRecurrent disease

from cervico-vesical ligamentfrom cervico-vesical ligamentsuperior vesicle art. sacrificed superior vesicle art. sacrificed 3/43/4thth of vagina, of vagina, , ,

VV RadicalRadical Resection includes portion Resection includes portion Recurrent diseaseRecurrent disease of distal ureter and bladderof distal ureter and bladder

Extent of SurgeryFive classes of hysterectomy (Piver, 1974) cont..Five classes of hysterectomy (Piver, 1974) cont..

Stage IA1Stage IA1 <0.5%<0.5%

Stage IA2Stage IA2 8% (0-13%)8% (0-13%)

Stage IBStage IB 12-20%12-20%

Stage IIAStage IIA 20-38%20-38%

Febrile morbidityFebrile morbidity Bladder dysfunctionBladder dysfunction Fistulae – VVF, UVFFistulae – VVF, UVF Ureteric stenosisUreteric stenosis Neuropathies Neuropathies Thrombo-embolismThrombo-embolism LymphoceleLymphocele Lower limb edemaLower limb edema GI complicationsGI complications

Lymph node metastases

Parametrial involvement

Positive surgical margins

Deep stromal invasion

Lymph-vascular space invasion

(LVSI)

Tumor size > 4 cm

Adjuvant Treatment after RHAdjuvant Treatment after RHRisk factors Risk category Adjuvant Rx

Nil Low Risk None

Deep stromal invasion

Tumor >4 cm

LVSI +ve

Intermediate

Risk

Adjuvant pelvic RT*

Lymph node +ve

Cut margin +ve

Parametrium +ve

High Risk Adjuvant Concurrent

CT + RT **

**Peters et al. J Clin Oncol.2000**Peters et al. J Clin Oncol.2000 **Sedlis et al. Gynecol Oncol.1999Sedlis et al. Gynecol Oncol.1999

any two

any one

Radical resection of the primary tumor with an adequate Radical resection of the primary tumor with an adequate clear margin +/- lymphadenectomyclear margin +/- lymphadenectomy

Types of surgeryTypes of surgery Stage of the diseaseStage of the disease

ConizationConization Stage IA1 without LVSI Stage IA1 without LVSI

Conization with BPLNDConization with BPLND Stage IA1 with LVSI Stage IA1 with LVSI

Radical Trachelectomy with BPLND Radical Trachelectomy with BPLND Stages IA2-IB1, Stages IA2-IB1, IA1 with LVSI IA1 with LVSI

Trachelectomy Trachelectomy LymphadenectomyLymphadenectomy

Vaginal Laparoscopic

Extra-peritoneal

Abdominal

- Dargent et al (1994) described the technique- Dargent et al (1994) described the technique..

Eligibility criteria:Eligibility criteria:

◦ Desire to preserve fertility.Desire to preserve fertility.

◦ Upto FIGO stages IB1( <2cm).Upto FIGO stages IB1( <2cm).

◦ Limited endo-cervical involvement.Limited endo-cervical involvement.

◦ No evidence of pelvic lymph node metastasis.No evidence of pelvic lymph node metastasis.

Pelvic lymphadenectomyPelvic lymphadenectomy

Frozen sectionFrozen section

Negative Nodes Negative Nodes

Radical trachelectomyRadical trachelectomy

If resection margins positive / nodes positiveIf resection margins positive / nodes positive

Radical hysterectomyRadical hysterectomyCervical circlage suture to ↓Cervical circlage suture to ↓ the risk of abortion. the risk of abortion.

Contraception for 6-12 mths.Contraception for 6-12 mths.

↑↑second trimester abortions, premature second trimester abortions, premature rupture of membrane, choriamnionitis, rupture of membrane, choriamnionitis, and preterm deliveries.and preterm deliveries.

Delivery by elective classical caesarean Delivery by elective classical caesarean section. section.

Authors Total No Pregnancies Authors Total No Pregnancies No. of Rec. DeathsNo. of Rec. Deaths

birthsbirths

Shepherd Shepherd 9595 4343 2626 3 3 11

Dargent Dargent 9696 5555 3636 4 4 33

CovensCovens 80 80 2222 1212 7 7 00

RoyRoy 6666 3737 2424 2 2 11

Schneider 36Schneider 36 0707 0404 1 1 00

Burnett Burnett 2121 0303 0303 1 1 00

Schlaerth 12Schlaerth 12 0404 0404 0 0 00

TOTALTOTAL 406406 171171 109109 18(4.4%) 18(4.4%) 5(1.2%)5(1.2%)

Risk of Ovarian Metastases in Early Cervical Risk of Ovarian Metastases in Early Cervical

CaCa::

SCCSCC 0.5% (4/770)0.5% (4/770)

AdenocarcinomaAdenocarcinoma 1.7% (2/121)1.7% (2/121)

Adeno-squamous Adeno-squamous 0 (0/99) 0 (0/99)Sutton et al. Am J Obstet Gynecol. 1992Sutton et al. Am J Obstet Gynecol. 1992

Ovaries are detached from the uterus along with itsOvaries are detached from the uterus along with its

blood supply and transposed in an area away from blood supply and transposed in an area away from

thethe

radiation field, generally in the para-colic gutters radiation field, generally in the para-colic gutters

abovethe pelvic brim.abovethe pelvic brim.

Drawbacks of Ovarian Transposition:-Drawbacks of Ovarian Transposition:- 25% risk of benign ovarian cysts.25% risk of benign ovarian cysts. 50% ovarian failure.50% ovarian failure. Risk of occult metastasisRisk of occult metastasis

First draining lymph node of an anatomical regionFirst draining lymph node of an anatomical region

Helps in tailoring the extent of surgery.Helps in tailoring the extent of surgery.

Techniques:Techniques: Peri-tumoral injection of blue dye and/or Peri-tumoral injection of blue dye and/or

radioactive tracer.radioactive tracer.

Extensively used in melanoma, breast and vulvar Ca.Extensively used in melanoma, breast and vulvar Ca.

Still experimental in Cervical Cancer! Still experimental in Cervical Cancer!

Laparoscopic Radical Hysterectomy (LRH).

Laparoscopic Assisted Radical Vaginal Hysterectomy (LARVH).

Laparoscopic surgical staging.

Chemo-Radiotherapy in Ca Chemo-Radiotherapy in Ca Cervix Cervix Combination of CT and RT is superior to RT alone.Combination of CT and RT is superior to RT alone.

Chemotherapy: Cisplatin 40mg/m2/wk X 5-6 wks Chemotherapy: Cisplatin 40mg/m2/wk X 5-6 wks Radiation therapy: Combination of TELETHERAPY Radiation therapy: Combination of TELETHERAPY & & BRACHYTHERAPYBRACHYTHERAPY TELETHERAPY (EXTERNAL BEAM RADIATION TELETHERAPY (EXTERNAL BEAM RADIATION THERAPY)THERAPY) BRACHYTHERAPY (INTERNAL RADIATION)BRACHYTHERAPY (INTERNAL RADIATION)

INTRACAVITARYINTRACAVITARY LDRLDR

HDRHDR INTERSTITIAL INTERSTITIAL LDRLDR

HDR HDR

RECOMMENDED TOTAL RADIOTHERAPY DOSES

RADIOTHERAPY TREATMENT TO BE COMPLETED WITHIN 8 WKS

IJROBP 1993,1995,

85-9035-4050IIIB8535-4045-50IIB75-8030-3545IB/IIA

50-6050-600IA

TOTAL DOSE ‘A’

ICRT-LDR

POINT ‘A’

EXT. RT

PELVISStage

INTERSTITIAL BRACHYTHERAPY IN CERVIX

INDICATIONS:INDICATIONS:

• Extensive Parametrial DiseaseExtensive Parametrial Disease

• Narrow/distorted vaginaNarrow/distorted vagina

• Post-hystercetomy Recc.Post-hystercetomy Recc.

• Distal Vaginal involvementDistal Vaginal involvement

•Persistent disease after radical radiotherapy (EXT + Persistent disease after radical radiotherapy (EXT + ICA)ICA)Applicators: Applicators:

Syed-Neblett Template (LDR)Syed-Neblett Template (LDR)

Martinez Universal Perineal Interstitial Template (MUPIT-Martinez Universal Perineal Interstitial Template (MUPIT-HDR)HDR)

Management of Ca-CervixManagement of Ca-Cervix

EARLY

I-IIA

EARLY

I-IIA

ADVANCED

IIB – IVA IVA-IVB / REC

ADVANCED

IIB – IVA IVA-IVB / REC

SURGERY SURGERY RADICAL

RADIOTHERAPY +

CHEMOTHERAPY

RADICAL RADIOTHERAPY

+CHEMOTHERAP

Y

PALLIATIONPALLIATION

RADIOTHERAPY

CHEMOTHERAPY

RADIOTHERAPY

CHEMOTHERAPY

All stages can be treated with RTAll stages can be treated with RT Concurrent CT-RT is superior to RT Concurrent CT-RT is superior to RT

alonealone Surgery is the treatment of choice for Surgery is the treatment of choice for

early-stage cervical cancer.early-stage cervical cancer. Adjuvant treatment is recommended in Adjuvant treatment is recommended in

patients with poor prognostic factors.patients with poor prognostic factors. Preservation of fertility is possible in Preservation of fertility is possible in

selected patients.selected patients.