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بسم الله الرحمن الرحيم

Dr. Yousefi discusses the benefits and drawbacks of less radical surgery options for patients with early-stage cervical cancer, including ovarian transposition, extent of hysterectomy, and sentinel node mapping.

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بسم الله الرحمن الرحيم

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  1. بسم الله الرحمن الرحيم www.zohrehyousefi.com

  2. Less Radical Surgery for Patients with Early-Stage Cervical Cancer Dr.Yousefi Professor Mashhad University of Medical Sciences Gynecologist Oncologist www.zohrehyousefi.com

  3. Ovarian Transposition Extent of Hysterectomy lymph node metastasis Sentinel node mapping radical trachelectomy www.zohrehyousefi.com

  4. 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 www.zohrehyousefi.com

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  6. 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 www.zohrehyousefi.com

  7. 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 www.zohrehyousefi.com

  8. Extent of Hysterectomy Class-I Class-II Class-III www.zohrehyousefi.com

  9. 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 www.zohrehyousefi.com

  10. 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% www.zohrehyousefi.com

  11. Post-operative Morbidity • Febrile morbidity • Bladder dysfunction • Fistulae – VVF, UVF • Ureteric stenosis • Neuropathies • Thrombo-embolism • Lymphocyst • Lower limb edema • GI complications www.zohrehyousefi.com

  12. Less Radical Surgery • Review of 1063 cases of stage IA2 • Rate of lymph node mets: < 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 www.zohrehyousefi.com

  13. Less Radical Surgery • In low risk disease • Stage Ib1 • < 2 cm • LVSI - • Rate of lymph node metastasis: • < 5% Kinney WK. Gynecol Oncol 57:3-6, 1995 www.zohrehyousefi.com

  14. Pelvic LN Metastasis in Early Cervical Ca Stage IA1 <0.5% Stage IA2 8% (0-13%) Stage IB 12-20% Stage IIA 20-38% www.zohrehyousefi.com

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  16. Adjuvant Treatment after RH any two any one www.zohrehyousefi.com *Sedlis et al. Gynecol Oncol.1999 **Peters et al. J Clin Oncol.2000

  17. Less radical surgery • Parametrial invasion • Literature review of ptes with • low-risk pathological characteristics: • Tumor size < 2 cm • Stromal invasion < 10 mm • Negative pelvic nodes • No LVSI • Risk of PI was 0.63% (5/799) www.zohrehyousefi.com Stegeman et al. Gynecol Oncol 2007; 105: 475

  18. Less radical surgery • Sentinel node mapping • Particularly effective in small lesions (< 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 www.zohrehyousefi.com

  19. Less radical surgery • Relationship between SN vs PI status • 158 ptesIA2/IB1 • If SN +: risk of PI 28% • If SN - : risk of PI 0% if • Tumor < 2 cm • Stromal invasion < 50% Strnad P et al. Gynecol Oncol 2008; 109: 280 www.zohrehyousefi.com

  20. Parametrial SN Ureter Sup. vesical artery Obturator nerve uterine artery Right parametrial SN Right obturator SN www.zohrehyousefi.com

  21. radical trachelectomy for cervical cancer www.zohrehyousefi.com

  22. The formal name of this operation is radical vaginal trachelectomy (RVT) and also known as the Dargent operation and radical trachelectomy. www.zohrehyousefi.com

  23. Trachelectomies, broadly, can be divided into the simple and radical variants. www.zohrehyousefi.com

  24. A simple trachelectomy refers to the removal of the cervix; this can be considered to be a very large conization procedure www.zohrehyousefi.com

  25. 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 www.zohrehyousefi.com

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  28. Radical trachelectomy • Indications • Women under 40 • Cancers up to Stage Ib (IIa) • Strong desire to maintain fertility www.zohrehyousefi.com

  29. Over 90 carried out at St Bartholomew’s Hospital 3 recurrences and 1 death 26 live births www.zohrehyousefi.com

  30. What is done? One stage procedure Pelvic Lymphadenectomy and Trachelectomy Two stage procedure Pelvic Lymphadenectomy and if nodes negative Then Trachelectomy www.zohrehyousefi.com

  31. Lymphadenectomy Intraperitoneal Extraperitoneal Laparoscopic As the principle is to preserve fertility logically The intra-peritoneal approach should be avoided. www.zohrehyousefi.com

  32. 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. www.zohrehyousefi.com

  33. Radical trachelectomy • Dargent et al, 1994 • Cx + parametrium + upper vagina removed • Pelvic lymphadenectomy • Isthmic-vaginal anastomosis • Isthmic cerclage www.zohrehyousefi.com

  34. 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. www.zohrehyousefi.com

  35. 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 www.zohrehyousefi.com

  36. Pregnancy Pregnancy can be achieved But 25% chance of miscarriage 30% + risk of premature labour 100% risk of Caesarean Section www.zohrehyousefi.com

  37. Early Stage Disease Preservation of Fertility Radical Trachelectomy and extra-peritoneal Pelvic Lymphadenectomy Shepherd et al. 1998, 10 cases, 6 pregnancies, 3 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. www.zohrehyousefi.com

  38. 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 www.zohrehyousefi.com

  39. T HANK YOU www.zohrehyousefi.com

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