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SURGICAL APPROACH TO GYNAECOLOGICAL CANCERS. Prof Greta Dreyer Head: Gynaecological Oncology University of Pretoria South Africa. OUTLINE. Cervical cancer Endometrial cancer Ovarian cancer. Cervical cancer. Surgery for : DISEASE CONFINED TO CERVIX FREELY MOBILE TUMOUR Not for :

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surgical approach to gynaecological cancers

SURGICAL APPROACH TO GYNAECOLOGICAL CANCERS

Prof Greta Dreyer

Head: Gynaecological Oncology

University of Pretoria

South Africa

outline
OUTLINE

Cervical cancer

Endometrial cancer

Ovarian cancer

cervical cancer
Cervical cancer

Surgery for:

DISEASE CONFINED TO CERVIX

FREELY MOBILE TUMOUR

Not for:

The very old

The medically - or immunocompromised

Etc…

cervical cancer4
Cervical cancer

Mainstay:

Radical abdominal hysterectomy with pelvic node clearance without removal of gonads

(RH/ND)

But:

Surgery tailored to the tumour size

Alternatives available

long term results of rh nd
Long term results of RH/ND
  • Excellent survival and tumour control
  • Morbidity and survival increased by post-op adjuvant (chemo)radiation
  • Bladder nerve injury with
    • Inability to empty
    • Detrussor instability
  • Some vaginal disfunction
  • Classical radiation complications
alternatives to rh nd
Alternatives to RH/ND
  • Radical trachelectomy with (laparoscopic) pelvic nodes without removal of uterus
  • Modified radical hysterectomy with (limited) pelvic nodes
  • Neo-adjuvant chemotherapy followed by definitive surgery
  • Consider oophorectomy for (large) adenocarcinomas
cervical cancer7
Cervical cancer

“SINS”:

  • Inappropriate non-radical hysterectomy
    • Hysterectomy without pap-test
    • Hysterectomy without specific diagnosis of abnormal pap test
  • Continuing to remove cervical tumour incompletely when stumbled upon
  • LLETZ as biopsy of visible tumour
endometrial cancer
Endometrial cancer

“Generalist’s cancer”

AND

Overall outcome excellent

BUT

Outcome per stage worse than cervical cancer

Majority of patients are staged incompletely

endometrial cancer9
Endometrial cancer

Radiation used to salvage incomplete surgery

Appropriate post-operative radiation improves local control

Radiation NOT shown to improve survival

endometrial cancer10
Endometrial cancer

Surgery for:

Everyone…

Two approaches – early and late stage

Not for:

Parametrial (paracervical) disease

Metastatic disease (outside abdomen)

early stage endometrial cancer
“Early stage” endometrial cancer

Definition:

Tumour confined to pelvic area

Determine risk for nodal metastases:

Tumour grade (grade 2+)

Tumour size (2 cm+)

Cervical / adnexal involvement (stage 2+)

Myometrial involvement (any)

High age (65?)

surgical approach to early stage endometrial cancer
Surgical approach to “early stage” endometrial cancer

Low risk:

TAH + BSO

Washings

?node sampling

Higher risk:

Above PLUS formal pelvic node dissection

Consider upper abdominal staging (clear cell and papillary serous)

Consider radical hysterectomy (cervix)

late stage endometrial cancer
“Late stage” endometrial cancer

Definition:

Tumour (probably) not confined to pelvic area / uterus and adnexae

AIMS:

Tumour debulking as for ovarian cancer

Maximum information for logical adjuvant treatment

surgical approach to late stage endometrial cancer
Surgical approach to “late stage” endometrial cancer

Pelvic clearance:

~always possible

NOT if advanced parametrial disease

Includes removal of pelvic nodes – normal and involved

Upper abdominal staging / debulking:

Omentum

Visible disease

Para-aortic nodes

results of appropriate surgery for endometrial cancer
Results of appropriate surgery for endometrial cancer

Early stage

  • Better stratification for adjuvant treatment
  • Less referral for radiation
  • Acceptable surgical morbidity

Late stage

  • More aggressive treatment of late stage
  • Improved outcome of late stage
ovarian cancer
Ovarian cancer

Pitfalls

Pre-operative evaluation

Surgical approach

Surgery for recurrent cancer

pitfalls in ovarian cancer
Pitfalls in ovarian cancer
  • Unsuspected and undiagnosed cancer
  • Unsuspected extent of disease leading to incomplete surgery
  • Inappropriate surgical team
  • POOR PREPARATION
pre operative evaluation
Pre-operative evaluation

RMI

Medical status

Extent of disease

  • Clinical evaluation
  • Radiology
  • Tumour markers
risk for malignancy index rmi
RISK FOR MALIGNANCY INDEXRMI
  • Ca 125 value x
  • Ultrasound score (0-5) x
  • Menopausal status (1 or 3)
complete surgery for ovarian cancer
Complete surgery for ovarian cancer

Early stage ovarian cancer

STAGING

Late stage ovarian cancer

DEBULKING

surgery for early stage ovarian cancer
Surgery for early stage ovarian cancer
  • Appropriate incision
  • Washings
  • Remove adnex and tumour bed completely, can retain fertility
  • Peritoneal staging
  • Omentum
  • Pelvic nodes
intra operative accurate staging of ovarian cancer
Intra-operative accurate staging of ovarian cancer
  • USO=minimum tumour surgery
  • Omentectomy=mandatory & easy
  • Peritoneal biopsies=super easy
  • Draining l/n=pelvic & para-aortic
  • Upper abdomen exploration = inspection and multiple biopsies
upstaging of apparent early ovarian cancer
Upstaging of apparent early ovarian cancer
  • USO
  • Omentectomy 20%
  • Multiple pelvic peritoneal biopsies 5-10%
  • Draining lymph nodes 20%
  • Upper abdomen 10-15%
surgery for late stage ovarian cancer
Surgery for late stage ovarian cancer
  • WHO should operate??
  • Midline incision (scopic)
  • Ascites and assess operability
  • Pelvic clearance (retroperitoneal)
who should operate late stage ovarian cancer
Who should operate late stage ovarian cancer

Worst survival = general surgeon

Second = generalist gynaecologist

Best outcome = gynaecological oncologist

Numbers increase survival(>10)

surgery for late stage ovarian cancer26
Surgery for late stage ovarian cancer
  • Total omentectomy
  • Appendectomy
  • Peritoneal stripping
  • Consider limited bowel resection/anastomosis
  • Consider splenectomy
reasons given for suboptimal debulking
Reasons given for suboptimal debulking
  • 15 % patient factors
    • Unstable, age, medical disease
  • 2% pelvic tumour not resectable
  • 80% upper abdominal disease not resectable
extent of surgery for disseminated ovarian cancer
Extent of surgery for disseminated ovarian cancer
  • High M&M surgery
  • Prognosis poor if sub-optimal chemo-response

There is some logic in neo-adjuvant or induction chemotherapy

conclusion
Conclusion
  • Pre-operative evaluation extremely important for all diseases
    • Radiology
    • Laboratory
    • Clinical
  • WHO should be operated
  • WHO should operate
  • HOW to operate
  • WHEN to operate
conclusion30
Conclusion
  • Increasing emphasis on stratification and expert surgery
  • Total radical removal of disease
  • Collecting complete staging information on histology
  • Adapting surgical aggressiveness to tumour and patient
  • Induction chemotherapy to selected patients