Management of CA of cervix

Pelvic exenteration REF: Danforth’s Obstetrics and Gynecology, 10th Edition P.983

Treatment of Recurrent Cervical Cancer:

• Cervical cancer detected within the first 6 months after primary therapy is often termed persistent cancer, while that diagnosed later is referred to as recurrent disease.
• Appropriate treatment of recurrent cervical cancer is dictated by both the site of recurrence and the modality of primary therapy.
• In general, patients in whom locally recurrent disease develops following primary surgery should be considered for salvage radiation therapy.
• Conversely, surgical treatment should be considered for those patients with recurrent central disease who initially received irradiation.
• Distantly metastatic recurrent tumor is not amenable to either modality alone and is an indication for palliative chemotherapy and possibly radiation therapy for local control.
• Pelvic exenteration is usually the procedure of choice for centrally recurrent cervical cancer.

Radiotherapy with combination with chemotherapy

REF: Shaw’s 13^th ed p. 390 TRETMENT OF CERVICAL CANCER:

Follow up [Ref: Novak’s Gynecology I4/e, p 1436, 1426, 1418-1421, 1408; Danfroth’s Obs & Gynae 10/e, p 981, 982, 975, 977]

• This patient has stage Ib Ca cervix (i.e. clinical lesion confined to cervix).
• Management of Ca cervix consists of Primary management and Post-op management. Primary Mx of Ib                                             Radical hysterectomy + lymphadenectomy

(detailed Mx of Ib described ahead)

Post surgical management depends on presence or absence of risk factors.

• So here this patient has stage Ib Ca cervix

– She has undergone total radical hysterectomy, which is the appropriate primary management.

• Post-op it is found that carcinoma is extending to lower part of body of uterus.
• This is the tricky part of the question.

– an extension to uterus is given no consideration in FIGO clinical staging of Ca Cervix.

Furthermore Novak writes – “After a clinical stage is assigned and treatment has been initiated the stage must not be changed because of subsequent findings of either extended clinical staging or surgical staging”.

• So a finding of uterus involvement is not going to change the stage or the management.
• Post op. management (i.e. either follow up, radiotherapy or chemoradiation) is going to be determined by presence or absence of risk factors. In the question, no risk factor has been mentioned (uterine involvement is not a risk factor). So we assume that none are present and hence further management would be –> ‘follow up’

Management of Ca Cervix Primary Management of 

Note – Radiotherapy can also be used for stages la to Ila if patient is medically inooperable.

Trachelectomy or cervicectomy refers to surgical removal of cervix. In radical trachelectomy parametria and vaginal cuff are also excised along with removal of cervix. This is a fertility preserving alternative to radical hysterectomy in younger patients with early stage carcinoma.

Types of hysterectomy

Type I – Simple (extrafascial) hysterectomy routinely done for benign conditions for e.g. fibroid.

Type II – (Wertheim’s or modified radical hysterectomy) In type II along with hysterectomy, medial half of the cardinal and uterosacral ligaments and proximal 1-2 cm of vagina are also removed.

Type III – (Meigs radical hysterectomy) It includes removal of most of the uterosacral and cardinal ligaments and the upper one third of the vagina.

Both type II & type III hysterectomy includes pelvic lymph node dissection.

Type IV – (extended radical hysterectomy) In type IV, the periureteral tissue, superior vesical artery, and as much as 3/4th of vagina in addition are removed.

Type V (partial exenteration) – Portions of the distal ureter and bladder are resected. Type IV & V are rarely performed because radiotherapy is more adequate treatment in extensive disease.

These factors are seen during histopathological examination of specimens (uterus, cervix, parametria, vaginal cuff, lymph nodes etc.) of radical hysterectomy and lymphadenectomy.

Let’s also have a revision of Ca Cx staging

Best method of management of cervical cancer stage IIb and above (advanced stage) includes use of external radiation, brachytherapy implants and concurrent chemosensitization. Cisplatin based chemotherapy along with radiotherapy is the best treatment of choice in advanced stage cervical cancer.

FIGO Stage IA-1: Is managed conservatively with cone biopsy for preservation of fertility or with simple hysterectomy when fertility is not preferred.

Stage IA 2, IB, IIA: Preferred treatment of choice is radical hysterectomy with bilateral pelvic lymph node dissection.

In stage IIIB cervical carcinoma the cancer has extended beyond ther cervix to the pelvic wall with/ without causing hydronephrosis.

Cervical carcinoma of stage IIB to IVA is considered to be advanced stage cervical cancer.

Current evidence states that chemotherapy given along with radiation therapy significantly improves the outcome in such cases. Of the chemotherapeutic agents used, cisplatin is associated with better survival rates.

Carcinoma of cervix:

• Stage III A – Involvement of the lower third of the vagina.
  Stage III B – Involvement of a parametria to the sidewall or obstruction of one or both ureters on imaging

• Chemoradiation is the treatment of choice for this stage.

• Class II hysterectomy is also referred to as a modified radical hysterectomy or Wertheim’s hysterectomy and is well suited for patients with stage IA2 and small lesions that do not distort the anatomy.
• Schauta operation is for all cases of stage I A cervical cancer.
• Chemotherapy with palliative radiation is indicated for stage IV B.

Ref: Cain J., ElMasri W.M., Gregory T., Kohn E.C. (2010). Chapter 41. Gynecology. In F.C. Brunicardi, D.K. Andersen, T.R. Billiar, D.L. Dunn, J.G. Hunter, J.B. Matthews, R.E. Pollock (Eds), Schwartz’s Principles of Surgery, 9e.

Carcinoma cervix

B i.e. Obturator Lymph node 

Ans. Caesium

Ans. 80-85 and 85-90 gy

Ans. d. Concurrent chemoradiation