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MRCOG PART 2 SBAs and EMQs

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ESSAY 207 - CERVICAL CANCER

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		Posted by Aroosha B. Tue Aug 15, 2006 03:23 am
Factors determining the prognosis of cervical cancer are the age of the patient, because the cancer at this age have a good prognosis although the data is conflicting. Other factors which are important is the stage of cancer as a survival is more than 90 % in stage 1 A1 while it is 80 % for stage 1 B and decreases further with advancing age as a survival at stage 4 is only 10.5 %. This is because as tumor stage increases so does the tumor volume and with that the likely hood of lymphatic and vascular involvement increases. Lymph nod involvement is also very important as 5 year survival decreases in the presence of positive nodes. It has been suggested that adenocarcenoma of the cervices has a worse prognosis than their saquamous counterparts when compared stage for stage, although data on it is conflicting. Certain rare tumor types such as small cell and neuroendocrine tumors are associated with poor prognosis. The objective of surgical treatment for invasive carcinoma is to remove the bulk of tumor with clear margins and with the decreasing morbidity. Surgery for stage 1 A1 tumor is in the form of local excision because the risk of lymph node metastases is order of 0.5 %. So local treatment would suffice. It has survival of 95% if excision margins are not clear than re excision should be done.Surgery at this stage is associated with best prognosis and decreased morbidity. A hysterectomy can be done if there is any gynaecological condition. Surgery for stage 1 A2 was done by lapartomy to remove lymph nodes and a radical hystectomy was done as abdomen was open for lymph adenectomy but this approach was associated with considerable morbidity and modern trend now is to remove local tumor in the form of excision by cone biopsy with clear margins and lymph nods assessed and removed laproscopically. This approach has a advantage of decreased morbidity and as well as fertility can be spared. The risk of positive lymph node is 7 %. Surgery for stage 1 B and 2A is either by radical surgery or by radiotherapy. Radical surgery is associated with bowel and bladder dysfunction. Vesico or utretero vaginal fistulas may result either as direct injury or indirectly due to devescurlrization. It may also result in pelvic lymphocyte formation The advantage is that ovaries can be spared as risk of ovarian involvement at this stage is very unlikely and sexual function can also be retained as radiotherapy results in vaginal stenosis. Fertility sparing surgery in the form of radical trachelectomy involves removal of cervices, upper vagina and proximal cardinal ligaments with laproscopic removal of lymph nodes. A Cervical suture is applied at the same time with delivery always by abdominal route. When counseling the patient it should be made clear hat long term data are not available and premature delivery may occur in 60 % cases. It must be considered an experimental procedure at present time. Surgery has a very little role in the management of stage 2 B 3 & 4, because it is not possible to remove whole tumor and chemo radiotherapy is the treatment at thes
		Posted by Srivas P. Tue Aug 15, 2006 04:40 am
The options of treatment for carcinoma Cervix include conservative conisation, radical Wertheim?s hysterectomy, palliative care, radiotherapy and chemotherapy depending on staging of cancer and this multimodal input is best possible under one roof in a cancer centre involving multi disciplinary team of gynecologic oncologists, medical and surgical oncologists, radiotherapists and specialist nurses, minimizing delays in referrals and improving prognosis. Prognosis also depends on staging of the disease and survival; varies from 20-30 % in stage IV to 93-95 % in Stage Ia Ca Cx. The prognosis also depends on distant metastasis and lymph node metastasis though the current clinico-investigative staging has not included nodal status in planning treatment. Lymph node involvement reduces survival stage for stage. Hence the recent interest in including CT scan and MRI to study LN involvement and tumour volume. Laparoscopy has been done to do LN sampling prior to do planned major surgery and restricting radical wertheims hysterectomy to node negative cases while node positive cases are initiated on primary chemo radiation. The survival rates of patients with early cervical cancer are the same whether the initial treatment is surgical or non surgical, though the long term morbidity is much more and prolonged with radio therapy. The surgical options used in early Ca Cx can be less radical so as to preserve the uterus for future fertility since the survival rates are good with less radical surgery. For stageIa1 ca cx, conisation or simple hysterectomy could suffice while for stageIa2 and stageIb1 Ca Cx, fertility preserving radical trachelectomy or conisation is possible as there is only 7% chance of LN involvement. Radical hysterectomy is another option if no need for preserving uterus. For large >2 cm StageIb1, Ib2 and stage IIa Ca Cx with negative nodes radical hysterectomy can be done by abdominal or vaginal route. For all stages beyond stage IIb Ca cx primary radiotherapy is preferred because of 30-50% nodal involvement and there would be need for adjuvant radiotherapy following surgery thereby increasing morbidity by multimodal treatment. Surgical option is possible if she has no medical contraindications to major surgery but it increases mortality from VTE, hemorrhage and infection. In comparison radiotherapy has low mortality but has greater (5-15%) late morbidity like chronic diarrhea, radiation cystitis, vaginal stenosis, bowel obstruction and fistulae which may necessitate a surgery anyway later with greater morbidities on a radiation exposed patient. Surgery preserves the ovaries and her fertility and prevents early menopause while radiation destroys the ovaries. Hence radiotherapy is reserved for later stage ca cx and early node positive cases which would need adjuvant radiotherapy even after surgery?so primary radiotherapy has less morbidity and preferred. This also preserves the uterus facilitating giving radiotherapy. Hence Primary surgical treatment in late stage ca Cx doesn?t have advantages. Surgery also has a place in recurrences after primary radiotherapy and pelvic exenteration can have 50 % cure rates but high 8% mortality and 30-50 morbidities.
		Posted by Kishor S. Tue Aug 15, 2006 07:53 am
The biopsy report is incomplete and we need to know details to determine the prognosis. First factor to determine the prognosis is the stage of the disease. In her case, it is most likely to be a microinvasive disease (stage Ia1 and Ia2), which will be indicated by the extent of invasion beneath the basement membrane and surface extent of the lesion. However, if the margins are not free of tumour, more invasive areas cannot be ruled out. Second prognostic factor is the histological type: squamous (Large cell keratinizing / Large cell non ? keratinizing / small cell type) or adenocarcinoma. Adenocarcinoma generally carries a poorer prognosis than squamous cancer and of the squamous, small cell type is the most virulent and LCK is the most differentiated, hence best prognosis. Third factor is lymphatic and vascular involvement / emboli because of the increased chance of spread. The objectives of primary surgical treatment are removal of the tumour along with the possible sites of spread; retaining of ovaries and leaving a functional vagina. This is possible till stage IIa. Though the staging is not altered, surgery gives an opportunity to assess the extent of the disease surgico-pathologically and conserving the ovaries in young females. Removal of tumour is done by cone biopsy, different levels of hysterectomy and lymphadenectomy. Type of surgery depends on the stage of the disease. In this present woman, if the biopsy margins are not free of tumour, cone biopsy should be done to assess thoroughly the extent. There will be two possibilities of outcome. The cone biopsy contains the whole of the lesion and the invasion is <3 mm. Then she does not need any additional surgery. But she requires regular follow up with pap smears and also, there are likely late complications such as cryptomenorrhoea and preterm labour. In the event the invasion is > 3mm, more extensive surgery is required. In invasion 3 - 5mm, modified radical hysterectomy is indicated. Here only the medial portion of cardinal ligaments is removed and does not involve dissection of ureters from the ligaments. Pelvic lymphnodes are removed. Since the incidence of lymph node involvement is very less (<1%), many oncologists perform only pelvic lymph node sampling. However, identification of sentinel nodes is difficult and various studies to map the lymphatics with radioactive substance and dye injected into the substance of cervix. But the results are not consistent. Stages higher than Ia2 till IIa should have full standard radical hysterectomy (Type III) with pelvic lymphadenectomy with/without paraaortic lymph nodes. In locally invasive stages (Ib2 till IIa), use of cisplatin based neoadjuvant chemotherapy prior to surgery has shown a significantly better outcome (Cochrane evidence). Very rarely, if she is desirous of having children, radical trachealectomy has been shown to be an alternative with similar result. Ultraradical surgery such as exenteration is done in recurrent or advanced cases with some response. The objective of palliative surgery which is done in recurrent or advanced cases is to give temporary relief to the symptoms such as urinary/bowel obstruction or fistulae.
		Posted by neera B. Tue Aug 15, 2006 04:11 pm
Prognosis depends on stage of disease , degree of differentiation, volume of tumour, degree of lymph node involvement and lymphovascular space invasion, histologic type, patient characteristics like age , anemia and other medical diseases. Prognosis is worse with advancing stage, poorly diferentiated, large volume, tumours, which have involved paraaortic lymph nodes or infiltrated lymphatics or vascular spaces. Old and anemic women have worse prognosis . Treatment by MDT involving gynae oncologist in a cancer centre improves prognosis. Radical surgery treatment is an option for stage 1b and IIa cancer cervix . It helps to define the extent of disease , though MRI, IVP, and cystoscopy are the other alternatives to define extent of disease . It helps to remove as much tumour as possible. However , radiotherapy is as effective as surgery in treatment of stage 1b and IIa. But surgery permits ovarian coservation while radiotherapy is associated with premature ovarian failure . Cryopreservation of ova should be offered prior to radiotherapy. The risk of sexual dysfunction is also less with surgery as compared to RT. If tumour is left behind at surgery, giving post op radiotherapy increases morbidity even further. Surgical morbidity and mortality is chiefly due to anaesthetic risks, TE, infection, bleeding, urological injuries. Surgery helps in lymph node sampling for histopathology which is not possible by RT or CT. This helps to predict prognosis. Surgery aims to prevent and treat complications such as intesti nal obstruction and ureteric obstruction by dividing adhesions and urinary diversion /ureteric reimplantation. However , adhesions form postoperatively , this objective cannot be met totally. Trachelectomy for bulky stage 1b ca cervix is effective when combined with laparoscopic lymphadenectomy.Though morbidity is reduced compared to hysterectomy there is risk of cervical incompetence , so cervical incirclage should be done and subsequent delivery should be by caesarian. Palliative surgery for stage 3 and 4 cancer cervix aims to improve quality of life , though partial relief is attained through relief of intestinal obstruction / urinary diversion and survival is prolonged but cure is not possible. Exenteration is done for central recurrences but morbidity and mortality are high.
		Posted by Ebeinheizer S. Tue Aug 15, 2006 08:30 pm
Factors that determine the prognosis of invasive cervical carcinoma are the stage of the disease, histological/cell type of the cancer, whether adjuvant radio or chemo therapy was given and the centre/surgeon performing surgical intervention (if any). Patient?s motivation, family support and non-medical circumstances such as prayer and meditation also affects prognosis. As the patient is health, prognosis should be better compared to someone who is not fit with poor nutritional status. Advanced stage with spread to adjacent organs such as the uterus or vagina, involvement of lymph nodes and distant metastasis such as lung and brain gives poor prognosis. Early stage such as Stage 1A1 and 1A2 which are confined to cervix carries better prognosis. Certain histological type such as Clear Cell cancer are rare but carries poorer prognosis. Differentiation of the cell on cytology also determines prognosis. Poorly differentiated cells carry worse prognosis. Giving adjuvant radio or chemo therapy for Stage 1A2 and Stage 2 disease are shown to have better prognosis compared to surgery alone. However, this has to individualised and not applicable to all patients. Managing the case at a cancer centre or general gynaecology unit has significant bearing. Management at gynaecology oncology centre and surgery (if any) performed by Gynaecology Oncologist gives better prognosis. Excision of primary disease removes the underlying pathology. This has proven to improve prognosis and outcome. However, anaesthesia and surgery related morbidity such as ureteric and bladder injury are high. This is especially when more radical surgery such as Radical Whertheim?s Hysterectomy is performed. Even though surgery does prevent spread and recurrence, microscopic seedlings are known to occur. These could not be removed at surgery. Adjuvant radio or chemo therapy with its associated morbidity might be necessary in certain cases. Surgery improves the quality of life and gives symptomatic relief especially when symptoms such as bleeding, discharge and pain are present. However, this has to be balance against anaesthetic and surgical risks. Radiotherapy and chemotherapy as adjuvant or alternative has associated morbidity as well. For this patient, preserving sexual function is important. Surgery should aim to preserve the vaginal length and function. Fertility might be desired and if the stage of cancer permits, should also be considered in collaboration with the Gyanecologocal Oncologist and General Oncologist. In advanced disease, surgery can be palliative to improve quality of life. However, risk and benefit has to be balanced by individual patient?s condition.
		Posted by Sarwat F. Tue Aug 15, 2006 11:51 pm
Various factors important in determining prognosis in cervical cancer include age of the patient, stage of the disease, fitness for surgery, wishes for fertility, surgical expertise available, facilities for radiotherapy and patients preference. Age is important as at 37 years of age issues like fertility, conservation of uterus and ovaries are important. Stage of the disease is important as surgical treatment is advised upto stage IIa and radiotherapy preferred in later stages. Surgical treatment also depends on expertise available to perform complicated surgeries and patients preferences in view of associated complications. Fitness for surgery is less important in this particular patient as she is young. Various surgical treatments for invasive cervical cancer include cone biobsy, total abdominal hysterectomy, radical hysterectomy with pelvic lymph nodes dissection, werthiems hysterectomy, trachellectomy with preservation of uterus. Cone biopsy is done for very early stage cervical cancer. Specimen should include 1 cm margin of tumor free tissue to ensure complete removal. Advantages includes that it preserves fertility, does not require special surgical expertise, short operating time, quick recovery, short hospital stay. However disadvantages includes intraoperative complications like hemorrhage, infection and late complications of miscarriage and preterm labour if pregnancy is contemplated. Total abdominal hysterectomy is done in cases where of early stage cervical cancers where uterine conservation is not a priority or with coexistent problems like menorrhagia due to fibroids or adenomyosis. It can also be an option in situations where surgical expertise for werthiems hysterectomy are not available. Ovaries can be conserved as they are still functioning although there is a risk of premature menopause. There is a risk of involvement of pelvic lymphnodes in advanced stage diseases which makes hysterectomy a less favourable option. Radiotherapy in the form of brachy or teletherapy are needed in advanced stage diseases. Apart from this hysterectomy is a major surgical procedure which is not without its complications. There are anaesthetic and operative risks which include hemorrhage requiring blood transfusion, damage to bladder, bowel, ureter, return to theatre for additional stitches, wound dehiscence, infection, thromboembolism. Late complications include urinary problems and vault prolapse. Werthiems hysterectomy is preferred surgical procedure in early stage cervical cancer uptill stage IIa. It involves hysterectomy and removal of pelvic lymph nodes. It requires surgical expertise to identify and remove pelvic lymph nodes. There is again a risk of anaesthetic and operative complications as with hysterectomy plus there is a risk of lymphatic obstruction with lymphedema formation. Advantages include good prognosis after surgery and less need for postoperative radiotherapy. Trachelorraphy is another surgical procedure which involves conservation of uterus and is mainly indicated in women with early stage disease who want to preserve their fertility. It is combined with pelvic lymph node dissection to improve prognosis of disease. However data regarding its efficacy is not available widely and long term studies are needed to prove its effectiveness. Various surgical procedures for cervical cancer have pros and cons and selection of procedure is individualized according to stage of the disease, fertility issues and wishes of patients.
		Posted by Freha Z. Wed Aug 16, 2006 02:10 am
The incidence of cervical cancer has fallen in UK by 26% since past 15 years which is clearly due to cervical screening. Major factors that influence prognosis of cervical cancer are stage of disease and volume of tumour. 5year survival after 1b is 90% while 1b2 is 70%. Other factors are grade of tumour(well differentiated or poorly differentiated) and histological type (sqamous type 70% incidence decreasing now due to screening and glandular 10-15% later is more aggressive). Prognosis also depends on lymphatic spread and vascular spread. 5 year survival in stage1 node positive 66% and node negative . 40% women die due to uncotrolled pelvic disease and direct bone involvement is common. Vascular spread occurs to bones lung and liver. Women should be fully staged using FIGO system which is largely based on clinical assessment, chest X ray and cystoscopy. Radiological staging using MRI permits more accurate determination of disease extent and also assessment of lymph node status. Specialized gynae oncology teams should determine the management of women with cervical cancer. Surgery and radiotherapy are equally effective in early stage disease, whereas locally advanced disease relies on treatment by radiation or chemoradiation. In this women surgery will be the better option because of her age as it has advantage of conservation of ovarian function however after hysterectomy ovarian function declines within 2-3 years. Women who have surgery and adjuvant radiotherapy sufferfrom high morbiditythan those who had either surgeryor radiotherapyalone. 5 year survival rate is similar in surgery or radiotherapy for stage 1b/11a disease. Surgery alone reduces the risk of chronic bladder, bowel and sexual dysfunction associated with radiotherapy. Complications in hands of experienced surgeons are uncommon. It also permits the assessment of risk factors such aslymph node status. However, complications of surgery are fistula<1%, lymphocyst,prmary haemorrhage and bladder injury. Chronic bladder and bowel problems that require medical or surgical intervention occur in 8-13% women due to parasympathetic denervation. Adjuvant radiotherapy is recommended for positive pelvic nodes to reduce risk of recurrence. But there is no firm evidence of increased survival. Careful pre-op imaging can detect lymphadenopathy and reduce the number of women undergoing both modalities of treatment. If the women is willing to conserve fertility Trachelectomy is an option for small volume stage1b disease. But this technique is still under evluation.
		Posted by Ismatara B. Wed Aug 16, 2006 02:47 am
The major factors that will influence prognosis are: stage, volume, grade of tumour (degree of differentiation), histological type (adeno- or squamous carcinoma), lymphatic spread, and presence or absence of lymphovascular invasion, age and medical condition like anemia. Patient with advanced stage of disease, paraaortic and pelvic lymph node involvement, poorly differentiated, large volume tumour, histological type-adenosquasous, old age, anaemia, and performance status were all significant prognostic factors for reduction in progression-free interval and survival. Treatment in a cancer centre with involvment of multidisciplinary team: gynaecological and surgical oncologist as well as, medical pncologist, radiologists, pathologist, clinical nurse specialist, lymphoedema specialist and radiation therapist, improves the prognosis. The major objective of surgical treatment for invasive cervical cancer is cure by complete resection of tumour with clear margin of disease free tissue and minimal morbidity. In early stage disease (1a-2a) is same, whether primary treatment is surgical or radiotherapy. Other most important factor in selecting most appropriate treatment is age, medical co-morbidity, fertility requirements, associated other uterine or ovarian pathology (fibroid, prolapse,PID, ovarian mass) and likely relative morbidities of available treatment. In the 37 year women with invasive cervical cancer, surgical treatment is best as this can preserve the ovarian and vaginal function and fertility can be preserved in early (stage 1a1-1a2) disease, she has less likely to have any pelvic pathology or medical disorder, as she is apparently healthy. Morbidity is rarely severe and is usually short lived, stable and treatable. At the same time, high patient satisfaction that the cancer has been removed. But in surgical treatment, mortality may arise from venous thromboembolism(0.1-1%), haemorrhage, infection, urological injuries, lymphocyst formation and anaesthetic risks. In Radiotherapy, though mortality is zero, has more early and late morbidity (5-15%), chronic, poorly treatable, and progressive, and is associated with chronic diarrhoea,, bladder irritation, vaginal stenosis, radiation fistula or bowel obstruction-need surgery. Therefore surgery tends to be the primary treatment modality if complete resection with clear margins and negative lymph nodes are highly likely. Primary chemoradiation is reserved for more advanced tumour and patient?s inordinately high surgical risk. In stage 1a1 and low risk stage 1a2, loop excision, conisation or simple hysterectomy is adequate treatment. The choice depends on age, desire for fertility, presence and amount of surrounding CIN. The risk of lymphatic spread is <1% and 5-yr survival is > 95%. In Non FIGO low risk stage 1a2 treatment is same as stage 1a1 and for high risk stage 1a2 conisation or radical trachelectomy with lymph node dissection if fertility is desired and radical hysterectomy ( abdominal/vaginal or laporoscopy) if fertility not desired. Risk of nodal involvement is low-7%.Radical trachelectomy can also be done for stage 1b1 <2cm. And if stage 1b1 >2cm ? 2a1 (non bulky) radical hysterectomy (abdominal/vaginal or laporoscopy) is preferred. Adjuvant radiotherapy if lymph node involves (15%of 1b, 30% of 2a), or the resection margins are not clear. The advantage of conservative surgery is less morbidity and fertility preservation but in case of radical trachelectomy, trained personel is needed and there is inadequate data at present. But radical surgery is associated with complication mentioned earlier and lymphocyst formation. For all Stage beyond 2b is not suitable for surgery, because there is a high risk of nodal involvement (30% of 2b, 50% of 4) and resection margins are often positive. Adjuvant chemoradiation frequently needed with increased morbidity and no proven survival rate. So, primary chemoradiation is preferred. In patient with central recurrence after primary radiotheropy pelvic exentration has 50% cure rate. But there are increased mortality and morbidity (leakage from diversion, obstruction, infection, haemorrhage and thromboembolism) and reoperation rate.
		Posted by Kishor S. Thu Aug 17, 2006 08:02 am
Dear Paul thanks for your correction/comment. However, I would like to clear the following points for your comment. I have not suggested that the question has been set wrongly. What I meant was: I do not think such a report (a single line) will be given by any pathologist when the specimen is sent as colpospically directed biopsy. It is possible if the patient says in her own word. Question says: Abnormal smear which means cervix is expected to be grossly normal on naked eye, hence colposcopy has been done to localize the suspicious area from where biopsy has been taken. These facts are enough to suggest a microinvasive lesion. If a colposcopy were done in an already visible lesion, it is not a right approach. There is no controversy about the prognostic factors of histological types in cancer cervix. They are already in oncology text books and numerous evidences in literature as well as in practice. Aim for potential cure is not an objective that pertains to surgery only. Many patients do prefer to remove the tumor though the potential cure is the same with radiation. Removing the tumour is the objective of surgery whereas burning and killing the tumour cells are the objectives of radiotherapy. Conservation of reproductive function: if it means conservation of uterus, it never comes as a first objective in an invasive cancer except in selective stage Ia1 by cone biopsy. It is more of conservation of ovarian function and functional vagina. It is done by transfixing the ovaries away from the possible radiation field in case the histology warrants subsequently. Another important objective is to prevent long term effects of radiation which is progressive due to endarteritis. Many a time we do surgery in post menopausal patients with early cancer who are no longer sexually active with this objective in mind. This is the informed choice of the patient. Surgico-patholigical staging is as of now not a recommended procedure/objective according to FIGO. This is just an incidental advantage, not an objective
		Posted by Samir A. Fri Aug 18, 2006 10:18 am
The factors determining prognosis are the carcinoma stage, volume of the tumour, lymphovascular involvement, lymph node involvement, tumour histology, HPV (Human Papiloma Virus) status and age of the patient. The stage is the single most important prognostic factor, so very early stage (micro-inasive disease: stage I a1) has good prognosis (5 year survival>80%), stage I a2, and Ib the 5 year survival 80%, stage II 60%, stage III 40% and stage IV 20-30%. The bigger the tumour volume the worst the prognosis since the incidence of nodal metastases significantly increases with bigger volume.4 cm diameter is the cut off line beween stages Ib1 and Ib2 which determines the line of treatment. Lymph node involvement affects survival.The larger the numbers of involved nodes the worst the prognosis.For instance 5 year survival in stage Ib is 45% with positive nodes, but is nearly double that with negative nodes. Para-aortic node involvement is a marker of widespread dissemination and very few patient survive 5 years after diagnosis. The diffrentiation of the tumour is another prognostic factor. The well differentiated carcinoma has much better prognosis and 5 year survival rate if compared with poorly differentiated carcinoma of the same stage. The carcinoma histology is another factor. Adenocarcinoma has worse prognosis, Oat cell carcinoma, which is rare, has worst prognosis. The squamous cell carinoma with positive HPV has better prognosis than negative. The age has its own peognostic factor. The cervical carcinoma has worst prognosis in younger women than elders. The objectives of surgical treatment of invasive carcinoma are the removal of the primary and the draining lymph nodes in operable cases.Stage Ib1 or less aes operable.Staging is a clinical diagnosis. Additional to clinical diagnosis, laparoscopic assessment of nodal involvement,especially para-aortic node adds to the accuracy of the decision of operability. Stage Ia1(microinasive disease) has the risk of 0.5% of nodal involvement, justifying cone biopsy only if the woman wants to keep fertility. Stages from Ia2 - Ib1 with no imaging nodal involvement are for radical hystrectomy (total abdominal hystrectomy + BSO + pelvic lymphadenectomy) if the woman is premenopausal, fit for surgery and gave informed consent. The surgical treatment has the advantages of preserving the ovaries, hence no need for early use of HRT, preserve vaginal lubrication, acurate surgical staging post operatively,allow post operative radiotherapy if incomplete exicision of the tumour, resection margin is close to the tumour or pelvic nodes contain tumour.Post operative radiotherapy decreases recurrence but does not improve survival. Avoidance of the Radical radiotherapy complication (short term like skin reaction, bone marrow depression, cystitis, diarrhoea and long term such as early menpause, proctitis and rectal bleeding, malabsorption, intestinal obstruction, vaginal shortening, ureteric stenosis,vesico-vaginal fistula and lower limb oedma) are one of the main surgical objectives. The disadvantages of the surgical treament are anaesthesia complications, haemorrhage, bladder and ureter injuries, bladder and bowel dysfunction due to trauma to nerve plexuses. In summary the surgical treatment in the form radical syrgery has less morbidity than the primary radical treatment especially for young women. Urine diversion in stage IV aims to relieve obstruction, relieves fistula symptoms and improve quality of life but does not improve survival. It has its own problems of stoma care and frequent UTI. In few cases where still residual disease after primary radiotherapy, hystrectomy may be justified but less radical than that for primary surgery. It has the advantage of removal of the residual of the cancer but has the disadvantage of increased rate of complications with large fistula rate.
		Posted by WERTWERT Q. Fri Aug 18, 2006 03:49 pm
(1) Prognosis depends on tumour grade, lymph node involvement, vascular invasion, stage, volume of disease and histological type. Objectives of surgery are to give surgical staging; which influences prognosis and guides adjuvant treatment. To cure. To palliate and to preserve ovarian and reproductive function. In early cervical cancer, ie stage 1a1 - knife cone biopsy alone provides a cure, has minimal patient morbidity and preserves ovarian and reproductive potential. (there is a slight risk increase in PROM and Preterm labour and miscarriage though). If family is completed a simple TAH is recommended. In stage 1a2, again knife cone biopsy is adequate but there is risk of lymph node invasion - hence simultaneous pelvic node dissection warrented - the dissection of the paraaortic, external iliac and obturator nodes have complications including lymphoedema, lymphocyst formation, obturator nerve and ureteric damage + vascular injury. These risks are justified to identify those needing adjuvant chemoradiation. In stage 1b, those with small volume disease wishing for children - radical amputation of the cervix may preserve fertility though this is a new technique; there are potential problems with pregnancy loss problems. Again lymphnode dissection is warrented For most 1b patients that are fit; radical hysterectomy; + PLND is appropriate surgery. Though the cure rate is the same as radical radiotherapy; surgery has less morbifity (ie hpoefully avoiding radiotherapy with its risks of vaginal stenosis, radiation cystititis and proctitis). In good surgical hands; ureteric and bladder injury will be minimal; but voiding problems as a consequence of nerve injury may not be avoided. For patients with bulky disease where close surgical margins are likely, unfit patients, or where laparotomy has discovered positive lymph nodes confirmed by frozen section; radical radiotherapy and avoiding radical hysterectomy is appropriate. Patients with radical hysterectomy + radiation have the highest morbidity than radical radiotherapy alone. For disease above 1b; surgery has no curative role. Though fixing of one of the ovaries to the pelvic side wall and moving it out of the way of any potential radiotherapy treatment field may help preserve ovarian function, Surgery may have palliative role; mainly in diversion of faeces from any vaginal fistula by way of colostomy/ileostomy. Benefits of surgery are questionable if patient has a short time to live; and surgery to treat ureteric obstruction may be more unkind than allowing death through obstructive renal failure.
		Posted by Kishor S. Mon Aug 28, 2006 07:03 am
Dear Dr Paul, Needs clarification!! The prognostic factors you have given are universal for any cancer. Specific to cancer cervix the following questions arise. Tumor volume: How do you measure in different stages? What method do you suggest: USG, CT or MRI? Are they recommended by FIGO? Most importantly, is it possible to measure tumor volume in advanced cancers from stage IIB onwards? Tumour grade / degree of differentiation: What are they in respect to cancer cervix? Is it Broder?s classification? How do you get a report of tumor differentiation in squamous cell carcinoma? (Because you seem to disagree about the various types such as large cell keratinizing, non-keratinizing and small cell) In the second part, what is the place/objective of ultraradical surgery such as pelvic exenteration? Surgico-pathological staging, though it is useful in an individual patient, is not still a word accepted by international bodies in the surgical management of cancer cervix.