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Cancer of the Cervix - Treatment
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SurgeryPrimary treatment of cervical cancer by surgery is generally limited to the following:
RadiotherapyAll stages of invasive cervical cancer may be treated by radical radiotherapy using a combination of both external beam pelvic radiotherapy and intracavity brachytherapy. Chemotherapy by itself is generally limited to a palliative role as it does not in itself have curative potential. However, recent studies have shown that survival is improved in patients who receive chemo-radiation. External beam6 megavolt linear accelerator is used. A dose of 50-52 GY to the pelvis in 28 fractions using a four field technique is undertaken. More information on Radiotherapy treatment of gynaecological cancers is available here Treatment by StageStage Ia - microinvasive carcinomaA microinvasive lesion is now generally accepted as one in which the cancer invades the stroma to a depth of no more than 3 mm below the base membrane. These patients have less than l% risk of lymph node metastases, and therefore pelvic lymphadenectomy is not required as part of their treatment, except in some patients with lymphatic or blood vessel invasion. Patients with invasion greater than 1 mm but not greater than 3 mm without evidence of endothelial line space invasion (ELSI) may be treated effectively by cervical conisation or simple hysterectomy. If invasion is between 1 and 3 mm with evidence of endothelial line space invasion then some studies indicate an increased risk for lymph node metastases and a type 2 radical hysterectomy would be indicated along with a pelvic lymph-node dissection. Patients with classical Ia1 lesion may be adequately treated by conisation or simple hysterectomy if there is no endothelial line invasion. However, in the presence of endothelial line space invasion an extended hysterectomy (Type II radical hysterectomy) with a pelvic lymphadenectomy may be justified. Patients with Ia2 lesions should be treated by a type 2 radical hysterectomy with pelvic lymphadenectomy. Stage IbPatients with stage Ib1 lesions should be treated by type 3 radical hysterectomy and radical pelvic lymphadenectomy. Stage II and IIIPatients with Ib2 lesion may be treated by a type 3 radical hysterectomy with radical pelvic lymphadenectomy or by primary chemoradiation. Patients with stage 2 and 3 disease are generally treated by chemoradiation using external beam radiotherapy and concurrent platinum based chemotherapy. Stage IVPatients with stage 4 disease have their treatment very much individualised depending on the distribution of the disease. Surgical TechniqueMost hysterectomy procedures for cervical carcinoma are carried out through a Maylard's incision. This is a lower abdominal transverse muscle cutting incision. Following opening of the peritoneal cavity peritoneal washings are taken for cytological examination. These results are being accumulated as part of a clinical study. The parametrium, pelvic and para-aortic lymph node areas are palpated for evidence of induration which may suggest metastatic disease. If there is a suspicion of metastatic disease then appropriate biopsies and frozen sections will be undertaken and further treatment will be determined by these results. If there is no suspicion of spread of the tumour beyond the cervix then the majority of the gastro-intestinal tract is packed out of the pelvis. The round ligaments are divided giving access to the pelvic sidewalls. If the ovaries are being removed at the operation, then the ovarian vessels are ligated at the level of the pelvic brim. Otherwise the ovaries and tubes are dissected free of the uterine cornua and packed out at the pelvis with the gastrointestinal tract. The ureter is identified and dissected free of the peritoneum in the lower half to two thirds of its pelvic course. The peritoneum incision is carried across the vesico-uterine fold of the peritoneum and the bladder dissected from the front of the cervix down to the level of the anterior fornix. A radical excision is undertaken of the following lymph node chains:
The obliterated hypergastric vessel is picked up lateral to the fundus of the bladder and held under tension. The uterine artery is identified at its origin from the anterior division of the internal iliac artery. It is ligated and divided near its origin and the uterine artery dissected free off the top of the ureter. The ureteric tunnel is opened and the ureter reflected laterally off the parametrium. The bladder may be further dissected to a slightly lower level at this stage. The utero-sacral ligaments are divided and the peritoneum in the anterior aspect of the Pouch of Douglas is opened below the level of the cervix. The rectovaginal septum is opened and the rectum blunt dissected free from the back of the vagina. The cardinal ligaments and parametrium are clamped and divided half to two thirds of the way between the cervix and the pelvic side wall. The vagina is opened circumferentially and the uterus and cervix with a small vaginal cuff plus or minus tubes and ovaries, is removed. The vaginal vault is closed with continuous or interrupted sutures. The pelvis is not routinely reperitonealised. Suction drains are no longer routinely placed on the pelvic sidewalls, although the central area of the pelvis may be drained with a Blake's suction drain at the surgeon's discretion. References
Professor Alex J. Crandon PhD (Leeds), F.R.C.O.G. (Lond), F.R.A.C.O.G.,
C.G.O.
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