SURGICAL APPROACH TO GYNAECOLOGICAL CANCERS

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SURGICAL APPROACH TO GYNAECOLOGICAL CANCERS

• Prof Greta Dreyer
• Head Gynaecological Oncology
• University of Pretoria
• South Africa

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OUTLINE

• Cervical cancer
• Endometrial cancer
• Ovarian cancer

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Cervical cancer

• Surgery for
• DISEASE CONFINED TO CERVIX
• FREELY MOBILE TUMOUR
• Not for
• The very old
• The medically - or immunocompromised
• Etc

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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

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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

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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

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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

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Endometrial cancer

• Generalists cancer
• AND
• Overall outcome excellent
• BUT
• Outcome per stage worse than cervical cancer
• Majority of patients are staged incompletely

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Endometrial cancer

• Radiation used to salvage incomplete surgery
• Appropriate post-operative radiation improves
  local control
• Radiation NOT shown to improve survival

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Endometrial cancer

• Surgery for
• Everyone
• Two approaches early and late stage
• Not for
• Parametrial (paracervical) disease
• Metastatic disease (outside abdomen)

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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?)

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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)

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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

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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

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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

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Ovarian cancer

• Pitfalls
• Pre-operative evaluation
• Surgical approach
• Surgery for recurrent cancer

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Pitfalls in ovarian cancer

• Unsuspected and undiagnosed cancer
• Unsuspected extent of disease leading to
  incomplete surgery
• Inappropriate surgical team
• POOR PREPARATION

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Pre-operative evaluation

• RMI
• Medical status
• Extent of disease
• Clinical evaluation
• Radiology
• Tumour markers

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RISK FOR MALIGNANCY INDEX RMI

• Ca 125 value x
• Ultrasound score (0-5) x
• Menopausal status (1 or 3)

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Complete surgery for ovarian cancer

• Early stage ovarian cancer
• STAGING
• Late stage ovarian cancer
• DEBULKING

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Surgery for early stage ovarian cancer

• Appropriate incision
• Washings
• Remove adnex and tumour bed completely, can
  retain fertility
• Peritoneal staging
• Omentum
• Pelvic nodes

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Intra-operative accurate staging of ovarian cancer

• USOminimum tumour surgery
• Omentectomymandatory easy
• Peritoneal biopsiessuper easy
• Draining l/npelvic para-aortic
• Upper abdomen exploration inspection and
  multiple biopsies

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Upstaging of apparent early ovarian cancer

• USO
• Omentectomy 20
• Multiple pelvic peritoneal biopsies 5-10
• Draining lymph nodes 20
• Upper abdomen 10-15

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Surgery for late stage ovarian cancer

• WHO should operate??
• Midline incision (scopic)
• Ascites and assess operability
• Pelvic clearance (retroperitoneal)

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Who should operate late stage ovarian cancer

• Worst survival general surgeon
• Second generalist gynaecologist
• Best outcome gynaecological oncologist
• Numbers increase survival(gt10)

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Surgery for late stage ovarian cancer

• Total omentectomy
• Appendectomy
• Peritoneal stripping
• Consider limited bowel resection/anastomosis
• Consider splenectomy

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Reasons given for suboptimal debulking

• 15 patient factors
• Unstable, age, medical disease
• 2 pelvic tumour not resectable
• 80 upper abdominal disease not resectable

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Extent of surgery for disseminated ovarian cancer

• High MM surgery
• Prognosis poor if sub-optimal chemo-response
• There is some logic in neo-adjuvant or induction
  chemotherapy

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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

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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