Cervical cancer surgery: Difference between revisions
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==Overview== | ==Overview== | ||
The feasibility of surgery depends on the stage of cervical cancer at diagnosis. The mainstay of surgical management for cervical carcinoma is radical hysterectomy with pelvic lymphadenectomy. | The feasibility of surgery depends on the stage of cervical cancer at diagnosis. The mainstay of surgical management for cervical carcinoma is radical hysterectomy with [[pelvic]] [[lymphadenectomy]]. | ||
==Surgery== | ==Surgery== | ||
===In Situ Cervical Cancer<ref>http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_93</ref><ref name="pmid25112591">{{cite journal |vauthors=Roque DR, Wysham WZ, Soper JT |title=The surgical management of cervical cancer: an overview and literature review |journal=Obstet Gynecol Surv |volume=69 |issue=7 |pages=426–41 |date=July 2014 |pmid=25112591 |doi=10.1097/OGX.0000000000000089 |url=}}</ref>=== | ===In Situ Cervical Cancer<ref>http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_93</ref><ref name="pmid25112591">{{cite journal |vauthors=Roque DR, Wysham WZ, Soper JT |title=The surgical management of cervical cancer: an overview and literature review |journal=Obstet Gynecol Surv |volume=69 |issue=7 |pages=426–41 |date=July 2014 |pmid=25112591 |doi=10.1097/OGX.0000000000000089 |url=}}</ref>=== | ||
* '''Conization:''' | * '''Conization:''' | ||
* 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]]. | * 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 [[loop electrosurgical excision procedure]](LEEP) may be an acceptable alternative to cold-knife [[conization]]. | ||
:: [[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. | :: [[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<ref>http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_104</ref><ref name="pmid1394041">{{cite journal |vauthors=Sevin BU, Nadji M, Averette HE, Hilsenbeck S, Smith D, Lampe B |title=Microinvasive carcinoma of the cervix |journal=Cancer |volume=70 |issue=8 |pages=2121–8 |date=October 1992 |pmid=1394041 |doi= |url=}}</ref>=== | ===Stage IA Cervical Cancer<ref>http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_104</ref><ref name="pmid1394041">{{cite journal |vauthors=Sevin BU, Nadji M, Averette HE, Hilsenbeck S, Smith D, Lampe B |title=Microinvasive carcinoma of the cervix |journal=Cancer |volume=70 |issue=8 |pages=2121–8 |date=October 1992 |pmid=1394041 |doi= |url=}}</ref>=== | ||
*Standard treatment options for '''stage IA1 cervical cancer''' include the following: | *Standard treatment options for '''stage IA1 cervical cancer''' include the following: | ||
:*'''Conization:''' for microinvasive carcinoma when the depth of invasion is less than 3 mm and there is no vascular or lymphatic invasion is noted, and the margins of the cone are negative, [[conization]] alone may be appropriate in patients who wish to preserve fertility. | :*'''Conization:''' for microinvasive carcinoma when the depth of invasion is less than 3 mm and there is no vascular or [[lymphatic]] 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 | :* '''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''' include the following: | *Standard Treatment Options for '''Stage IA2 Cervical Cancer''' include the following: | ||
:* Modified radical hysterectomy with lymphadenectomy | :* Modified radical hysterectomy with lymphadenectomy | ||
:: For patients with tumor invasion between 3 mm and 5 mm, modified radical [[hysterectomy]] with pelvic | :: 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 | :* Other Treatment Options | ||
::* Radical trachelectomy | ::* 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. | ::: 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: | :::: Most centers utilize the following criteria for patient selection: | ||
::::: Desire for future pregnancy. | ::::: Desire for future [[pregnancy]]. | ||
::::: Age younger than 40 years. | ::::: Age younger than 40 years. | ||
::::: Presumed stage IA2 to IB1 disease and a lesion size no greater than 2 cm. | ::::: 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. | ::::: 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. | ::::: 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. | ::::: 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. | ||
===Stages IB and IIA Cervical Cancer<ref>http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_110</ref>=== | ===Stages IB and IIA Cervical Cancer<ref>http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_110</ref>=== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Monalisa Dmello, M.B,B.S., M.D. [2]
Overview
The feasibility of surgery depends on the stage of cervical cancer at diagnosis. The mainstay of surgical management for cervical carcinoma is radical hysterectomy with pelvic lymphadenectomy.
Surgery
In Situ Cervical Cancer[1][2]
- Conization:
- 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 loop electrosurgical excision procedure(LEEP) may be an acceptable alternative to cold-knife conization.
- 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[3][4]
- Standard treatment options for stage IA1 cervical cancer include the following:
- Conization: for microinvasive carcinoma when the depth of invasion is less than 3 mm and there is no vascular or lymphatic 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 include the following:
- 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.
- Most centers utilize the following criteria for patient selection:
Stages IB and IIA Cervical Cancer[5]
- Radical hysterectomy and bilateral pelvic lymphadenectomy with or without total pelvic radiation therapy plus chemotherapy
- Other Treatment Options
- Radical trachelectomy
- Patients with presumed early-stage disease who desire future fertility may be candidates for radical trachelectomy.
Recurrent Cervical Cancer[6]
- Pelvic exenteration
- For locally recurrent disease, pelvic exenteration can lead to a 5-year survival rate of 32% to 62% in selected patients
References
- ↑ http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_93
- ↑ Roque DR, Wysham WZ, Soper JT (July 2014). "The surgical management of cervical cancer: an overview and literature review". Obstet Gynecol Surv. 69 (7): 426–41. doi:10.1097/OGX.0000000000000089. PMID 25112591.
- ↑ http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_104
- ↑ Sevin BU, Nadji M, Averette HE, Hilsenbeck S, Smith D, Lampe B (October 1992). "Microinvasive carcinoma of the cervix". Cancer. 70 (8): 2121–8. PMID 1394041.
- ↑ http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_110
- ↑ http://www.cancer.gov/types/cervical/hp/cervical-treatment-pdq#section/_147