The Place Of Radical Surgery For Gynaecological Malignancies 2
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The Place of Radical Surgery for Gynaecological Malignancies By Dr. JAMES ENIMI OMIETIMI Department of Obstetrics & Gynaecology University of Port Harcourt Teaching Hospital Port Harcourt
INTRODUCTION
Over 20 years ago, the norm had been radical surgery for Gynaecological malignancies with a view to removing all malignant tissue as much as possible. However, this was associated with a lot of morbidity without necessarily reducing the mortality. This led to newer approaches to gynaecological oncology with a view to minimizing morbidity, restoration of functions and similar or improved outcomes in terms of survival.
Vulvar Carcinoma
Traditional managed by radical vulvectomy with en bloc dissection of the inguino-femoral nodes- Tausing and Way:-1940s. Improved 5 yr survival from 20-25% to 60-70%, but associated with about 85% wound breakdown. Since 1970s, the trend shifted towards more individualized treatment to reduce morbidity. Triple incision described by Byron et al in 1965 and later popularized by Hacker et al was associated with only 14% wound
Less radical surgery was prompted by the presence of microinvasive disease in younger women with small < 1cm in diameter and < 5mm invasion tumours. They also underwent bilateral jnguinal node dissections. A variety of procedures described as radical wide excision with margins ranging from 1cm-3cm; Hemivulvectomy- for lateral lesions Anterior vulvectomy- for anterior Posterior vulvectomy- for posterior Multifocality- 20-28% by Ross and Ehrmann in sq Ca Local recurrence of 7% for 165 patients- radical local excision and 6% for 365 patients- radical vulvectomyHacker et al. Generally accepted that a triple incision and less radical vulvar surgery are methods of choice with reduced morbidity & no apparent effect on recurrence.
Role of inguino-femoral node dissection Inguino-femoral node status is prognostic; 10
Inguino-femoral node status is prognostic; 1015% of stage 1-2 vulvar Ca. Superficial inguinal nodes act as a sentinel group. Radical inguino-femoral lymphadenectomy Bilateral inguinal lymphadenectomy associated with significant wound breakdown & chronic leg edema. Pelvic lymphadenectomy generally abandoned Adjuvant groin and pelvic radiotherapy improved survival compared with pelvic lymphadenectomy.
Other Treatment Modalities
Isosulphan blue Dye Lymphoscintigraphy with technetium-99 labelled colloid and an intra-operative gamma camera to identify sentinel nodes. Ultrasound scanning and FNAC Chemo-radiotherapy for sphincter preserving surgery in advanced carcinoma of the vulva.
CARCINOMA OF THE CRVIX
Stage 1ai -conisation Stage 1aii-simple hysterectomy Stage 1aii sq ca in young women – conisation suffices Early adenocarcinoma—controversial Stage 1b-radical surgery or pelvic radiotherapy with significant side effect profile for either modality; younger fitter patients opting for surgery & older less fit patients opting for radiotherapy.
Class 111 Radical Hysterectomy
Modified radical hysterectomy for stage 1b lesions <2cm reduced morbidity without necessarily compromising survival. For larger >6cm lesions, post operative radiotherapy is required. Larger doses of external beam radiotherapy or extrafascial hysterectomy advocated to improve survival. Surgery has not been proven to offer improved survival or reduced risk of
The role of lymph node sampling
Pelvic lymph node involvement is prognostic. Lymph node involvement in stage 1b disease has 55-60% 5yr survival, compared with an overall survival of 8590%. 15% of patients with stage 1 disease have nodal involvement. Adjuvant radiotherapy recommended when lymph nodes are involved. No proven improved survival but reduces local recurrence.
New surgical approaches for Ca Cervix
Shauta’s radical vaginal hysterectomy combined with laparoscopic pelvic lymphadenectomy for early carcinoma of the cervix. Survival in patients comparable with open surgery. Modification of radical vaginal hysterectomy by Dargent et al & Shepard et al- radical Trachelectomy; adequate local excisions of small volume stage 1b tumours but enables the preservation of fertility.
ENDOMETRIAL CARCINOMA
Choice of surgery; TAH + BSO TAH + removal of vaginal cuff Radical hysterectomy Role of lymphadenectomy; Unclear in early disease but indicated when lymph nodes are macroscopically involved. USA, routine with radiotherapy for nodal
OVARIAN CARCINOMA
Objective is to completely remove tumour or debulk as much as possible where residual macroscopic disease is inevitable. However, despite newer surgical techniques with increasingly radical surgery, no significant improvement in survival of patients with advanced disease. Meta analysis shows that the type of chemotherapy was the main influence on survival and cytoreductive surgery had minimal effect. Benefits exist for early disease or significant symptoms that can be relieved by surgery, but
Other treatment options
Neo-adjuvant chemotherapy CT scanning Cytology of ascitic taps Scan guided FNAB of pelvic or omental masses Open laparoscopy Minimal access surgery Gene therapy
SURGICAL PALLIATION
Gastrointestinal obstruction Fistulae Renal tract obstruction Localised masses
THE FUTURE
The greatest influences are likely to be in imaging & image guided biopsies. Improved understanding of disease behaviour through molecular prognistication. We are unlikely to find a cure for cancer in the short term by medical means, however we must continue to develop integrated strategies that extract the best we have and minimize the damage to individuals. Increased knowledge and awareness on the part of clinicians and patients alike can only serve to reduce the place of radical surgery in the management of
THANK
YOU
INTRODUCTION
Over 20 years ago, the norm had been radical surgery for Gynaecological malignancies with a view to removing all malignant tissue as much as possible. However, this was associated with a lot of morbidity without necessarily reducing the mortality. This led to newer approaches to gynaecological oncology with a view to minimizing morbidity, restoration of functions and similar or improved outcomes in terms of survival.
Vulvar Carcinoma
Traditional managed by radical vulvectomy with en bloc dissection of the inguino-femoral nodes- Tausing and Way:-1940s. Improved 5 yr survival from 20-25% to 60-70%, but associated with about 85% wound breakdown. Since 1970s, the trend shifted towards more individualized treatment to reduce morbidity. Triple incision described by Byron et al in 1965 and later popularized by Hacker et al was associated with only 14% wound
Less radical surgery was prompted by the presence of microinvasive disease in younger women with small < 1cm in diameter and < 5mm invasion tumours. They also underwent bilateral jnguinal node dissections. A variety of procedures described as radical wide excision with margins ranging from 1cm-3cm; Hemivulvectomy- for lateral lesions Anterior vulvectomy- for anterior Posterior vulvectomy- for posterior Multifocality- 20-28% by Ross and Ehrmann in sq Ca Local recurrence of 7% for 165 patients- radical local excision and 6% for 365 patients- radical vulvectomyHacker et al. Generally accepted that a triple incision and less radical vulvar surgery are methods of choice with reduced morbidity & no apparent effect on recurrence.
Role of inguino-femoral node dissection Inguino-femoral node status is prognostic; 10
Inguino-femoral node status is prognostic; 1015% of stage 1-2 vulvar Ca. Superficial inguinal nodes act as a sentinel group. Radical inguino-femoral lymphadenectomy Bilateral inguinal lymphadenectomy associated with significant wound breakdown & chronic leg edema. Pelvic lymphadenectomy generally abandoned Adjuvant groin and pelvic radiotherapy improved survival compared with pelvic lymphadenectomy.
Other Treatment Modalities
Isosulphan blue Dye Lymphoscintigraphy with technetium-99 labelled colloid and an intra-operative gamma camera to identify sentinel nodes. Ultrasound scanning and FNAC Chemo-radiotherapy for sphincter preserving surgery in advanced carcinoma of the vulva.
CARCINOMA OF THE CRVIX
Stage 1ai -conisation Stage 1aii-simple hysterectomy Stage 1aii sq ca in young women – conisation suffices Early adenocarcinoma—controversial Stage 1b-radical surgery or pelvic radiotherapy with significant side effect profile for either modality; younger fitter patients opting for surgery & older less fit patients opting for radiotherapy.
Class 111 Radical Hysterectomy
Modified radical hysterectomy for stage 1b lesions <2cm reduced morbidity without necessarily compromising survival. For larger >6cm lesions, post operative radiotherapy is required. Larger doses of external beam radiotherapy or extrafascial hysterectomy advocated to improve survival. Surgery has not been proven to offer improved survival or reduced risk of
The role of lymph node sampling
Pelvic lymph node involvement is prognostic. Lymph node involvement in stage 1b disease has 55-60% 5yr survival, compared with an overall survival of 8590%. 15% of patients with stage 1 disease have nodal involvement. Adjuvant radiotherapy recommended when lymph nodes are involved. No proven improved survival but reduces local recurrence.
New surgical approaches for Ca Cervix
Shauta’s radical vaginal hysterectomy combined with laparoscopic pelvic lymphadenectomy for early carcinoma of the cervix. Survival in patients comparable with open surgery. Modification of radical vaginal hysterectomy by Dargent et al & Shepard et al- radical Trachelectomy; adequate local excisions of small volume stage 1b tumours but enables the preservation of fertility.
ENDOMETRIAL CARCINOMA
Choice of surgery; TAH + BSO TAH + removal of vaginal cuff Radical hysterectomy Role of lymphadenectomy; Unclear in early disease but indicated when lymph nodes are macroscopically involved. USA, routine with radiotherapy for nodal
OVARIAN CARCINOMA
Objective is to completely remove tumour or debulk as much as possible where residual macroscopic disease is inevitable. However, despite newer surgical techniques with increasingly radical surgery, no significant improvement in survival of patients with advanced disease. Meta analysis shows that the type of chemotherapy was the main influence on survival and cytoreductive surgery had minimal effect. Benefits exist for early disease or significant symptoms that can be relieved by surgery, but
Other treatment options
Neo-adjuvant chemotherapy CT scanning Cytology of ascitic taps Scan guided FNAB of pelvic or omental masses Open laparoscopy Minimal access surgery Gene therapy
SURGICAL PALLIATION
Gastrointestinal obstruction Fistulae Renal tract obstruction Localised masses
THE FUTURE
The greatest influences are likely to be in imaging & image guided biopsies. Improved understanding of disease behaviour through molecular prognistication. We are unlikely to find a cure for cancer in the short term by medical means, however we must continue to develop integrated strategies that extract the best we have and minimize the damage to individuals. Increased knowledge and awareness on the part of clinicians and patients alike can only serve to reduce the place of radical surgery in the management of
THANK
YOU
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