❤️Zirakpur Escorts☎️7837612180☎️ Call Girl service in Zirakpur☎️ Zirakpur Cal...
Cervical cancer1
1. 8/9/1441
1
CERVICAL CANCER
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics
and gynecology
Ain Shams University
1
Facts
•According to the latest data from GLOBOCAN 2018, cervical
cancer is the fourth most common cancer in women
worldwide, and the second most common in low- and
middle-income countries
•In the UK, cervical cancer is the third most common
gynaecological malignancy after endometrial cancer and
ovarian.
•The incidence and mortality of cervical cancer has fallen
significantly since the introduction of the NHS Cervical
Screening Programme (NHSCSP) in 1988.
•Most cases in the UK are diagnosed in women under age of
45 years (52%) .
•54 % women diagnosed with cervical cancer have stage I
disease, while only 8% have stage IV disease.4/30/20 Elbohoty 2
2
2. 8/9/1441
2
•Squamous cell carcinoma (SCC), which accounts for more
than 70% of cases, and adenocarcinoma, which accounts for
approximately 25% of cases.
•For women with SCC, the incidence of ovarian metastasis is
very low <1% (0.2% for stage IB and 2% for stage IIB disease).
•As such, the ovaries can be preserved in women undergoing
surgery
•The incidence of ovarian metastasis is higher for women
with adenocarcinoma (4% for stage IB disease); hence, if
these women are to undergo surgery, most gynaecological
oncologists recommend BSO.
4/30/20 Elbohoty 3
3
The 10 Most Commonly Diagnosed Cancers in Females,
UK,2017
4/30/20
elbohoty
4
4
3. 8/9/1441
3
Risk factors
• High Risk HPV inection
• Use of CHC
• An estimated 10% of cervical cancers in the UK are linked to use of OCs.
Cervical cancer risk is up to doubled in current OC users who have used OCs
for 5+ years, compared with never users
• Early start of sexual life
• Multiparous
• Family history ?
• This probably reflects shared environmental risk factors including human
papillomavirus (HPV) infection, as well as possible genetic factors.
4/30/20 Elbohoty 5
5
Pathology type
• Squamous cell carcinoma- >70%.
• Adenocarcinoma- >25%.
• Other histologies – Rare
• Adenosquamous tumors exhibit both glandular and squamous
differentiation. They may be associated with a poorer outcome than
squamous cell cancers or adenocarcinomas
• Neuroendocrine or small cell carcinomas can originate in the cervix in
women but are infrequent
• Rhabdomyosarcoma of the cervix is rare; it typically occurs in adolescents
and young women.
• Primary cervical lymphoma and cervical sarcoma are also rare
4/30/20 Elbohoty 6
6
4. 8/9/1441
4
SPREAD:
Direct Lymphatic Blood (late and
rare)
- Vagina.
- Parametrium.
-Bladder and rectum.
-- parametrial spread
causes obstruction of
the ureters, many
deaths occur due to
uraemia.
-Obstruction to the
cervical canal results in
pyometria
A- primary node:
parametrial.
Paracervical.
Vesicovaginal.
Rectovaginal.
Hypogastric.
Obturator and external iliac
B-Secondary nodes:
Common iliac
Sacral
Vaginal
Paraaortic
Inguinal.
-.
-Blood to lung, CNS, ………
4/30/20 Elbohoty 7
7
Complications
•Uraemia.
•Fistulae (VVF or rectovaginal fistula)
•Obstruction of cervical canal by malignancy ® pyometra or
haematometra or pyo-haematometera or
pyophesometra ( gas forming organism ) .
4/30/20 Elbohoty 8
8
5. 8/9/1441
5
Clinical presentation
• Women with early invasive disease may be
• asymptomatic
• diagnosed through the cervical cytology screening programme and
referral for colposcopy
• It is important to realise, however, that a recent negative smear does
not exclude malignancy, since a necrotic tumour may not exfoliate
abnormal cells.
• Women may be referred following an abnormal smear and features of
invasive disease, such as atypical vessels, only become apparent at
colposcopy.
• If the practitioner taking the smear is suspicious regarding the cervical
appearance, referral for further investigation on an urgent basis is
warranted, irrespective of the smear result.4/30/20 Elbohoty 9
9
Clinical Picture :
Symptoms : Abnormal pap smear result
• Bleeding :
postcoital or intermenstrual bleeding
persistent vaginal discharge, which may be bloodstained
postmenopausal bleeding
•Discharge.
• Pain .
•Pressure symptoms ® UB – Ureter – Rectum .
4/30/20 Elbohoty 10
10
6. 8/9/1441
6
4/30/20 Elbohoty
If cervical cancer is suspected on examination
when a woman attends for cervical screening
she should be referred to gynaecology.
Women with symptoms suggestive of cervical
cancer should be referred to gynaecology if
cervical cancer is suspected on examination.
Examination
11
11
General look:
cachexia?
BMI
Lymphadenopathy
Local Examination :
Picture of the 1ry Local spread
1. As macroscopic picture . 1. Vaginal spread.
2. Examine mobility . 2. PR examination ..
3. Fistula ( UB or rectum )
.
4/30/20 Elbohoty 12
12
7. 8/9/1441
7
Cusco speculum
4/30/20 Elbohoty 13
A speculum examination may reveal an obvious
cervical tumour but an appropriate biopsy is still
required to confirm the diagnosis.
With large necrotic tumours, the central area
may not have any viable tumour and ideally
biopsies should be taken from the edge of the
tumour.
Once the diagnosis is confirmed, staging will be
undertaken
13
• Biopsy & histopathological examination .
To confirm the diagnosis initialy and plan futher adjuvant therapy
and followup :
4/30/20 Elbohoty
Pathology reports of cervical tumours should include the following histological
features:
1. Tumour type
2. Tumour size
3. Extent of tumour (eg involvement of the vaginal wall or parametrium)
4. Depth of invasion
5. Pattern of invasion (infiltrative or cohesive invasive front)
6. Lymphovascular space invasion (LVSI)
7. Status of resection margins (presence of tumour and distance from margin)
8. Status of lymph nodes (including site and number of nodes involved)
9. Presence of pre-invasive disease.
14
14
8. 8/9/1441
8
To certify spread
• Routine investigations and other methods (e.g., examination under
anesthesia, cystoscopy, proctoscopy, etc.) are not mandatory and are
to be recommended based on clinical findings and standard of care.
• Imaging and pathological assessment of the pelvis and
evaluation of pelvic and para-aortic lymph nodes should be
formally incorporated into the staging of cervical cancer while
giving the clinician the flexibility to use it according to available
resources.
4/30/20 Elbohoty 15
15
FIGO 2018 recommendations:
• Allowing the use of any imaging modality and/or pathological findings for
stage allocation
• In stage I, amendments to microscopic pathological findings and to size
designations, allowing the use of imaging and/or pathological assessment of
the size of the cervical tumour
• In stage II, allowing the use of imaging and/or pathological assessment of
size and extent of the cervical tumour
• In stages I–III, allowing assessment of retroperitoneal lymph nodes by
imaging and/or pathological findings and, if metastatic, the case is
designated as stage IIIC (with notation of method used for stage allocation).
• No recommendations for routine investigations, which are to be decided on
the basis of clinical findings and standard of care.
4/30/20 Elbohoty 16
16
9. 8/9/1441
9
Imaging
•Methods of imaging may include ultrasound, CT, MRI,
PET, PET-CT, MRI-PET, etc., based on local resources.
•MRI has been shown to be better than CT in assessing
the size of the lesion and parametrial infiltration. It also
improve triage of patients into surgical treatment (either
radical hysterectomy or fertility-preserving radical
trachelectomy) or primary chemoradiotherapy.
•The utility of imaging for evaluation of parametrium and
upper vagina in comparison to EUA is less clear.
•For women with contraindications to MRI scanning CT is
appropriate.
•For women with clinically apparent stage IVA or IVB
disease, post contrast spiral or multislice CT scans of
chest, abdomen and pelvis are more appropriate than
MRI.
4/30/20 Elbohoty 17
17
Clinical examination
• The EUA should include a combined rectovaginal examination to assess
parametrial and vaginal extension +/- cystoscopy and sigmoidoscopy.
• Colposcopy may be used to assess the extent of vaginal involvement.
• Examination under anaesthesia may be useful to improve the accuracy of clinical
assessment where imaging facilities are lacking
• Evaluation of the bladder and rectum by cystoscopy and proctosigmodoscopy,
respectively, is recommended if the patient is symptomatic or imaging suspects
involvement.
• Cystoscopy should be considered in cases with a barrel-shaped endocervical
growth, extension of growth to the anterior vaginal wall.
• A chest X-ray (CXR) should be performed to examine for lung metastases or pleural
effusion.
4/30/20 Elbohoty 18
18
15. 8/9/1441
15
Stage I:
The carcinoma is strictly confined to the cervix uteri (extension to the corpus should be disregarded)
•IA Invasive carcinoma that can be diagnosed only by microscopy, with maximum depth of invasion <5 mm
• ○IA1 Measured stromal invasion <3 mm in depth
• ○IA2 Measured stromal invasion ≥3 mm and <5 mm in depth
•IB Invasive carcinoma with measured deepest invasion ≥5 mm (greater than stage IA), lesion limited to the cervix uterib
• ○IB1 Invasive carcinoma ≥5 mm depth of stromal invasion and <2 cm in greatest dimension
• ○IB2 Invasive carcinoma ≥2 cm and <4 cm in greatest dimension
• ○IB3 Invasive carcinoma ≥4 cm in greatest dimension
Stage II:
The carcinoma invades beyond the uterus, but has not extended onto the lower third of the vagina or to the pelvic wall
•IIA Involvement limited to the upper two-thirds of the vagina without parametrial involvement
• ○IIA1 Invasive carcinoma <4 cm in greatest dimension
• ○IIA2 Invasive carcinoma ≥4 cm in greatest dimension
•IIB With parametrial involvement but not up to the pelvic wall
Stage III:
The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or
non-functioning kidney and/or involves pelvic and/or paraaortic lymph nodesc
•IIIA Carcinoma involves the lower third of the vagina, with no extension to the pelvic wall
•IIIB Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney (unless known to be due to another cause)
•IIIC Involvement of pelvic and/or paraaortic lymph nodes, irrespective of tumor size and extent (with r and p notations)c
• ○IIIC1 Pelvic lymph node metastasis only
• ○IIIC2 Paraaortic lymph node metastasis
Stage IV:
The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum. A
bullous edema, as such, does not permit a case to be allotted to stage IV
•IVA Spread of the growth to adjacent organs
•IVB Spread to distant organs
4/30/20 Elbohoty 29
29
Staging
• Imaging and pathology can be used, when available, to supplement
clinical findings with respect to tumor size and extent, in all stages.
• The involvement of vascular/lymphatic spaces does not change the
staging. The lateral extent of the lesion is no longer considered.
• Adding notation of r (imaging) and p (pathology) to indicate the
findings that are used to allocate the case to stage IIIC. For example,
if imaging indicates pelvic lymph node metastasis, the stage
allocation would be stage IIIC1r and, if confirmed by pathological
findings, it would be Stage IIIc1p. The type of
• Imaging modality or pathology technique used should always be
documented. When in doubt, the lower staging should be assigned.
4/30/20 Elbohoty 30
30
16. 8/9/1441
16
Treatment
• The treatment decision will be made in a multidisciplinary meeting
involving gynaecological oncologists, clinical oncologists, radiologists and
pathologists.
• Factors influencing treatment are
• Disease stage, age, fertility wishes, performance status.
• Aim of treatment:
• Curative
• Palliative
• Options
• Surgery
• radiotherapy
• chemoradiotherapy
4/30/20 Elbohoty 31
31
Microinvasive cervical carcinoma IA1
• Fertility preservation: LLETZ or a cone biopsy
• Woman who have completed their family: simple hysterectomy (type
1) may also be utilised. This can be done via an abdominal, vaginal, or
laparoscopic route.
• If LVSI is positive: pelvic lymphadenectomy should be considered,
along with modified radical hysterectomy.
• The incidence of positive lymph nodes is less than 1% and therefore, if
the excision margins are clear of disease (invasive and pre-invasive), no
further treatment is necessary. Careful cytological and colposcopic
follow-up is essential.
• If simple hysterectomy is chosen in the presence of incomplete
margins, a repeat loop or cone should be performed to exclude more
extensive invasive disease that could necessitate a radical
hysterectomy.
4/30/20 Elbohoty 32
32
17. 8/9/1441
17
Stage IA2
•Fertility preservation:
•cervical conisation or simple trachelectomy with
laparoscopic pelvic lymphadenectomy; or
•Radical abdominal, vaginal, or laparoscopic trachelectomy
with pelvic lymphadenectomy.
•Woman who have completed their family:
•In low risk cases: simple hysterectomy with pelvic
lymphadenectomy
•High risk cases: Type B radical hysterectomy or more
radical surgery is usually performed + pelvic
lymphadenectomy is performed.
4/30/20 Elbohoty 33
33
Stage IB1
•Fertility preservation:
•Radical abdominal, vaginal, or laparoscopic trachelectomy
with pelvic lymphadenectomy.
•Woman who have completed their family:
•Type C radical hysterectomy + pelvic lymphadenectomy is
performed.
4/30/20 Elbohoty 34
34
18. 8/9/1441
18
Stage IB2 &IIA1 < 2cm
•Surgery or radiotherapy can be chosen as the
primary treatment depending on other patient
factors and local resources, as both have
similar outcomes.
•The aim is to use a single modality of
treatment whenever possible since the
morbidity is much increased when
radiotherapy is given in addition to surgery.
4/30/20 Elbohoty 35
35
Stage IB3 and IIA2
•Concurrent platinum-based chemoradiation
•The tumours are larger and the likelihood of high risk factors
such as positive lymph nodes, positive parametria, or
positive surgical margins that increase the risk of recurrence
and require adjuvant radiation after surgery are high.
4/30/20 Elbohoty 36
36
19. 8/9/1441
19
Stage IIB to IVA
• Concurrent platinum-based chemoradiation
• A survival benefit of approximately 30% with the addition of chemotherapy but had higher
short- and medium-term complications.
• The cure rate is between 20 and 50% and, if not cured, most patients will have a significant
reduction in tumour size and improvement in their symptoms, particularly vaginal
discharge and neuropathic pain. The dose of radiotherapy can be reduced in the very frail
and where the intention is palliation rather than cure.
• Patients with Stage IVA disease may have only central disease without
involvement to the pelvic sidewall or distant spread. Pelvic exenteration can be
considered but usually has a poor prognosis
4/30/20 Elbohoty 37
37
Stage IVB
• 2 % of cases
• Concurrent chemoradiation
4/30/20 Elbohoty 38
38
20. 8/9/1441
20
Routine follow-up
• Visits are recommended every 3–4 months for the first 2–3 years, then 6-
monthly until 5 years, and then annually for life.
• At each visit, history-taking and clinical examination are carried out to detect
treatment complications and psychosexual morbidity, as well as assess for
recurrent disease.
• Routine imaging is not indicated.
4/30/20 Elbohoty 39
39
Chemotherapy
• Chemotherapy is given in combination with radiotherapy to patients with bulky
stage IB or higher stage disease, as well as those deemed unfit for surgery.
Concurrent chemo-radiation reduces the risk of relapse or death by 30–50%
when compared with radiotherapy alone, although potentially serious
haematological and gastrointestinal toxicity can occur.
• Typically, cisplatin is used weekly for up to six doses during the course of
radiotherapy.
• A number of anticancer drugs have activity in metastatic and relapsed cervical
cancer; however, there is no standard chemotherapy treatment. Active agents
include cisplatin, ifosfamide, paclitaxel, bleomycin and gemcitabine.
• Patients with metastatic or relapsed cervical cancer should be considered for
entry into a clinical trial.
4/30/20 Elbohoty 40
40
21. 8/9/1441
21
4/30/20 Elbohoty
Cervical cancer 5-year survival
relative to stage
Stage 5-year survival
(%)
LN
I 95.9 15%
II 47 30%
III 22 50%
IV 5.3% 41
The overall 5-year survival rate is 67%, but this
depends on stage:
41
Radical hysterectomy
• Surgery involves removal of the pelvic lymph nodes from the common iliac artery
to the femoral canal. There is no clear role for the routine removal of the para-
aortic nodes.
• To achieve adequate clearance of the tumour, the ureters are mobilised and the
ureteric tunnels exposed, to allow paracervical removal along with a vaginal cuff.
• Serious complications include haemorrhage, damage to the bladder, ureter or
bowel, venous thrombosis and pulmonary embolus.
4/30/20 Elbohoty 42
In the longer term, there is a
small risk of lymphoedema
(3%), sexual dysfunction (2%)
and bladder dysfunction
(3.5%).
Surgery is usually preferable
in the medically fit younger
patient, with the potential
advantages of preservation of
ovarian and sexual function.
42
22. 8/9/1441
22
Trachelectomy
• It can be done by open abdominal, vaginal, or by minimally invasive
routes.
• When a vaginal approach is planned, the pelvic nodes are first
removed laparoscopically and sent for frozen section to confirm node
negativity, and then the radical trachelectomy can proceed vaginally.
• Alternatively, the nodes may be first be assessed by conventional
pathologic methods, and the radical trachelectomy performed as a
second surgery after 1 week.
• The patient should be counselled carefully, including on the
implications for future pregnancies, an increased incidence of
miscarriage and premature delivery.
4/30/20 Elbohoty 43
43
Radical Trachelectomy
• To remove the cervix with surrounding
tissue (parametrium and upper vagina)
in order to achieve oncological
clearance of the central tumour, while
retaining the uterus (uterus-sparing).
• The uterine isthmus and vagina are re-
anastomosed and a permanent suture
is inserted in the isthmic part of the
uterus to mechanically tighten the
lower opening of the uterus, thus
creating a ‘neo-cervix’.
Depending on pre-trachelectomy histological parameters, it may be oncologically
appropriate to preserve a small portion of the proximal cervix at the internal os: this is
thought to reduce some of the potential obstetric complications following trachelectomy.
4/30/20 ELBOHOTY 44
44
23. 8/9/1441
23
Remove ovary (not needed)
• Involvement of ovary: Involvement of the ovary has been reported in
<1% of cases of squamous cell carcinoma and in <5% of cases
• It can be only considered in adenocarcinomaq
4/30/20 Elbohoty 45
45
Ovarian transposition
•If irradiating the pelvis becomes essential in the
management of cervical cancer, ovarian transposition may
be considered.
•Ovaries can be hitched up and sutured to the mid abdominal
sidewall whilst their blood supply is preserved.
•They need to be transposed well above the level of the
pelvic brim if they are to be excluded from the radiation
field.
•This procedure may prevent early menopause and ovaries
may be used at a later date for oocyte retrieval, in vitro
fertilisation (IVF) and achieving pregnancy through surrogacy
if appropriate
4/30/20 Elbohoty 46
46
24. 8/9/1441
24
Need of adjuvant therapy
•If the surgical margins are close to tumour or
the lymph nodes are involved in tumour
adjuvant pelvic radiotherapy should be
considered.
•The combination of radiotherapy and surgery
significantly increases morbidity and the aim
of preoperative imaging is to minimise the
need for this combination.
4/30/20 Elbohoty 47
47
Pelvic exenteration
•It involves the en bloc removal of some or all of
the pelvic organs, i.e. uterus, fallopian tubes
and ovaries, vagina, urethra, bladder and
rectum (and occasionally the anal canal, vulva
and perineum), with urinary and faecal
diversion in one stoma (ureterosigmoidostomy)
4/30/20 ELBOHOTY 48
48
25. 8/9/1441
25
Its value
•As pelvic exenteration is associated with significant
morbidity and mortality, case selection for such
surgery with palliative intent is critical to avoid
surgery-associated deterioration in quality of life
(QoL), and the palliative care team must be involved
in the decision-making.
•Nowadays, these operations are most often
performed for recurrent gynaecological cancers that
have previously been irradiated, and less often for
locally advanced/persistent disease following
primary treatment with radiotherapy or
chemoradiotherapy
4/30/20 ELBOHOTY 49
49
Indications
• the most common indication for exenteration is recurrent
cervical cancer following RT
• with or without chemotherapy and with or without prior radical
surgery).
• Most recurrences occur within 3 years of primary treatment, with a 5-year
survival rate in recurrent cervical cancer ranging from 6% to 77%.
• Less common indications include recurrent endometrial (or
uterine) cancer and recurrent vulval and vaginal cancer.
• in exceptional cases of recurrent ovarian cancer with persistent
pelvic disease following RT.
• Because recurrent endometrial and ovarian cancers are more often
associated with metastatic abdominal and nodal disease, exenterative
surgery is not appropriate in most of these cases.
• Pelvic exenteration is also performed to provide local control of
recurrent urological cancers, as well as primary, locally advanced
and recurrent rectal cancer.4/30/20 ELBOHOTY 50
50
26. 8/9/1441
26
Prepration
• Preoperative assessment is crucial to improve case selection for what can be
viewed as a higher risk and mutilating operation.
• This is best effected by a coordinated team approach.
• For many patients with post-radiation recurrent disease, exenteration offers the
only possibility for cure, and this must be balanced with operative complications
and postoperative mortality, and noncurative alternative treatment options.
• Exenterative surgery has been considered for recurrent disease of the central
pelvis with no extension to, or involvement of, the lateral pelvis.
• Patient education is important regarding treatment options, surgical procedures,
options regarding urinary/faecal diversion, and the various reconstructions
including vaginal reconstruction.
• Emphasis must be placed on QoL and the patient’s attitudes, as well as her
wishes in the decision-making process.
• Clinical nurse specialists have a key role before and after surgery. The dilemma is
to effect cure without seriously reducing QoL – that is, adequate resection (R0)
and appropriate pelvic reconstruction.
• Treatment decisions should be based on the performance status of the patient,
site of recurrence and/or metastases, the absence of metastatic disease, prior
treatment, and the patient’s psychological wellbeing and wishes. .4/30/20 ELBOHOTY 51
51
Classification of exenteration
4/30/20 ELBOHOTY 52
52
27. 8/9/1441
27
Poor prognostic factors
• Poor patient performance status
• Obesity, diabetes mellitus, cardiorespiratory disease
• Psychological frailty
• Short time to recurrence (disease-free interval / treatment-free
• interval) <2 years
• Metastatic disease in pelvic lymph node(s)
• Metastatic disease in para-aortic lymph node(s)
• Positive peritoneal fluid/washings
• Size of lesion (>5 cm in any dimension)
• Histological margin status (R1, R2)
• Histological evidence of infiltration of blood vessels, lymphatics or perineural disease*
4/30/20 ELBOHOTY 53
53
Pregnancy after trachelectomy for early
cervical cancer
4/30/20 ELBOHOTY 54
54
28. 8/9/1441
28
Why and when to offer radical trachelectomy ?
• Cervical cancer is the 12th most common cancer in women in the
country.
• Worldwide, cervical cancer still remains the fourth most common
cancer in women, with over 60% of women surviving the disease for
10 years or more, reflecting the improved survival rates.
• Approximately 52% of women with cervical cancer in England and
Wales are under the age of 45 years
• While the standard treatment for stage IA2 or IB1 cervical cancer is a
radical hysterectomy, radical trachelectomy has been shown to have
equivalent 5-year survival and is a surgical option if there is a wish to
preserve fertility.
4/30/20 ELBOHOTY 55
55
Can Trachelechtomy be replaced by cone excision?
• In light of growing observational, non-randomised evidence that the risk of
parametrial involvement for women with low- volume, low pathological risk
tumours is less than 1%, a number of groups have now published case series on
less radical surgery for such women, for example, knife cone with laparoscopic
bilateral pelvic lymph node dissection.
• However, it is imperative that a change to less radical surgery, fertility-preserving
or not, is only done without a detrimental impact on oncological outcome.
4/30/20 ELBOHOTY 56
56
29. 8/9/1441
29
Pregnancy and delivery after radical trachelectomy
•Pregnancies following trachelectomy are high risk because of
the increased rate of mid-trimester miscarriage and preterm
delivery, often as a consequence of preterm prelabour rupture
of membranes.
•Delivery is by caesarean section, traditionally by classical
section as a permanent isthmic suture is placed at the time of
trachelectomy, but nowadays a transverse incision may be
used to reduce morbidity and the implications on future
fertility.
4/30/20 ELBOHOTY 57
57
Oncology Outcome
• The oncological results of a radical trachelectomy are comparable to a radical
hysterectomy, with a 5-year survival of 95–98% according to Cancer Research UK
data.
• Recurrence rates appear to be the same irrespective of whether the
trachelectomy is performed by the vaginal, abdominal, laparoscopic or robotic
approach.
• With the earlier detection of cervical cancer and an increase in the number of
women undergoing fertility- sparing surgery, women with post-trachelectomy
pregnancies are increasingly encountered in obstetric practice.
4/30/20 ELBOHOTY 58
58
30. 8/9/1441
30
Obstetrics outcome
• The spontaneous conception rate suggest that up to 61% of women who
conceived following a trachelectomy required assisted reproduction techniques to
achieve a pregnancy.
• The mean time from surgery to conception was 31 months, with the mean
surgical follow-up period of 47 months.
• The pooled live birth rate of women pregnant following trachelectomy was 62.8%,
• The rate of first trimester miscarriage is 16%, which is similar to the rate among
the general population of 15–20%.
• The rate of second-trimester miscarriage is 7% which is higher than the general
population rate of 4%.
• Most of the second-trimester miscarriages are caused by infection and PPROM.
• The percentage of women who delivered at term was 54.8%.
4/30/20 ELBOHOTY 59
59
Role of the cervix during pregnancy
• The cervical length, the internal os and the endocervical mucus plug play an
important role in maintaining cervical competence and preventing ascending
infection.
• A shortened cervix (or neo-cervix in women following trachelectomy) is thought
to lead to a loss of mechanical, cellular, biochemical and immunological barriers
resulting in cervical (isthmic) incompetence, ascending infection, higher risk of
second-trimester miscarriages, prematurity, PPROM and chorioamnionitis.
• Detection of labour may be difficult to assess as there may be painless
progressive dilatation of the neo-cervix leading to mid- trimester miscarriages
and preterm labour (25–28%)
4/30/20 ELBOHOTY 60
60
31. 8/9/1441
31
ANC
• early referral for consultant-led obstetric care with multidisciplinary input
• Vaginal progesterone pessaries may be considered from 12 weeks (200mg twice a day) until 36 weeks
• Serial fortnightly isthmic length scans
• Urine should be tested for culture and sensitivity and vaginal cultures for bacterial vaginosis at the first
obstetric visit, and any infections should be treated. Additionally, consider prophylactic antibiotics if
clinically indicated at 16 and 24 weeks
• Consider a course of two doses of prophylactic steroids from 24 weeks of gestation if there are signs of
preterm labour or delivery appears imminent
• Avoid unnecessary vaginal digital examinations
• Consider avoiding sexual intercourse from 20 weeks onwards as this may be a source of infection
• Consider avoiding strenuous activities such as heavy lifting, exercise or prolonged periods of standing in
the second trimester onwards
• Avoid elective dental work during pregnancy to minimise risks of infection and preterm birth resulting
from periodontitis
• Commence antibiotics and prophylactic steroids if premature rupture of membranes occurs
• Aim to deliver by elective caesarean section around 37 weeks, but maintain a low threshold for delivery in
case of preterm prelabour rupture of membranes as there is a high risk of subclinical chorioamnionitis
4/30/20 ELBOHOTY 61
61
Management of Miscarriage
• In the event of a first- trimester miscarriage, medical management is
recommended without having to remove the cerclage.
• Surgical evacuation can be performed through the isthmic cerclage with
neocervical dilatation to Hegar size 7 if required, preferably under ultrasound
guidance.
• This should be undertaken by a senior clinician, as locating the neo-cervix may be
difficult with an increased risk of perforation.
• When managing second-trimester miscarriages, the cerclage may need to be
removed before the prostaglandin regimen is commenced. The role of
hysterotomy remains contentious, depending on the gestation
4/30/20 ELBOHOTY 62
62
32. 8/9/1441
32
PTL
• compared to a cervical conisation procedure: Preterm labour is directly
correlated to the excision of a core depth of more than 10 mm of cervical tissue
(relative risk –2.59, 95% CI 1.80–3.72).
• Risk of preterm delivery post- trachelectomy is 45%. Overall, 55% of women
delivered in the third trimester.
• Serial isthmic or neo-cervical length scans to monitor isthmic shortening and
funnelling along with simultaneous active screening for genital infections are
recommended.
• There is no evidence to recommend consideration of insertion of an additional
suture, which can be technically difficult.
4/30/20 ELBOHOTY 63
63
How to prevent PTL
•Screen and treat infection:
•Prophylactic antibiotics and fortnightly infection screening
from 16 weeks: as isthmic suture itself may be a cause of
infection
•Some clinicians advise women to use condoms during sexual
intercourse and avoid spas and swimming pools to minimise
the risk of infection during pregnancy
•Vaginal progesterone pessaries have been shown to
decrease the rate of preterm labour in non-treated
asymptomatic women with a short cervix (with particular
reference to spontaneous delivery before 34 weeks) from
34% to 19% in the treated group, although not specifically in
those who have had a trachelectomy.
4/30/20 ELBOHOTY 64
64
33. 8/9/1441
33
Delivery
• The mode of delivery should be by a planned or prelabour caesarean section, as
there is a risk of uterine rupture and severe haemorrhage if contractions
commence.
• The main problem during a caesarean section is the absent or poorly formed
lower segment caused by severe distortion following cervical amputation, with
the risk of an extension of the transverse lower segment uterine incision into the
uterine arteries causing catastrophic haemorrhage.
• Traditionally, a classical caesarean section with a midline vertical upper segment
incision was recommended; nowadays there is growing evidence on the safety of
a transverse incision by lower segment or high transverse incision to reduce
morbidity and risks of future fertility issues, such as repeat caesarean section
and placental implantation problems.
• A transverse incision may be considered if the lower segment is sufficiently well
developed.
• Technical difficulty in obtaining adequate exposure at surgery and haemorrhage
should be anticipated, and the presence of a senior clinician at surgery is
recommended. In view of the anticipated difficulties at delivery, timing of the
procedure is recommended by 37 weeks to avoid the woman going into
spontaneous labour and requiring an emergency caesarean section.4/30/20 ELBOHOTY 65
65
Contraception
•Contraception is advised for 6 months after trachelectomy
• Since the cervix is removed, the progesterone-only pill,
which relies on the action of cervical mucus, which is lost,
may be ineffective as a method of contraception.
•Insertion of an intrauterine system may be technically
challenging because of difficulty locating the isthmic os and
isthmic stenosis. In order to reduce this complication, some
surgeons insert a urinary catheter through the isthmus
during the trachelectomy and leave it in place for three days
post- surgery.
•Intrauterine system insertion should be attempted by an
experienced clinician.
4/30/20 ELBOHOTY 66
66
34. 8/9/1441
34
Cervical cancer during pregnancy
4/30/20 Elbohoty
67
Effect of pregnancy
•Pregnancy causes marked morphological changes to the
cervix, which include a significant increase in cervical
volume, a bluish hue due to increase in vascularity,
ectropion and inflammatory changes.
•These physiological changes may appear suspicious to an
inexperienced clinician.
•Performing a cervical smear during pregnancy is not
recommended.
•Cervical smears performed during pregnancy frequently
cause concern as the presence of decidual cells can be
mistaken for atypia.
4/30/20 Elbohoty
68
35. 8/9/1441
35
Diagnosis
• Any vaginal bleeding: speculum examination
• A suspected cervical lesion in pregnancy should immediately be
referred for colposcopic examination by an accredited colposcopist.
• Patients with a visible lesion on the cervix should have a directed
biopsy.
• a cervical biopsy should be taken, usually under general anaesthesia,
since the cervix has increased vascularity during pregnancy and there
is a risk of significant haemorrhage
• One directed biopsy from the most dysplastic area is usually
performed to establish the histological diagnosis.
• The risk of a punch biopsy during pregnancy is increased bleeding due
to increased vascularity of the cervix but there are no increased risks
to the pregnancy.
4/30/20 Elbohoty
69
Staging
•Staging of cervical cancer is based on clinical
examination but in the UK magnetic resonance
imaging (MRI).
•MRI is the best imaging modality for assessment of
local and regional spread and is safe in pregnancy.
The clinical assessment of the parametria is difficult
and less reliable in pregnancy
•CT scanning carries a risk of radiation exposure to
the fetus in pregnancy and so is not used in assessing
pregnant women with cervical carcinoma.
4/30/20 Elbohoty
70
36. 8/9/1441
36
Early-stage disease (IA1, IA2 and B1)
• Continuation of the pregnancy after treatment with LLETZ, conisation or a
radical trachelectomy and consideration of pelvic lymphadenectomy to
assess disease spread.
• Cases of stage IA1, IA2, and small IB1 cervical cancers should be managed on
an individual basis, the tumour type and size being key factors in determining
treatment.
• Stage IA1 tumours can be managed by LLETZ or cold-knife cone alone.
• LLETZ or cold-knife conisation should be undertaken early in the pregnancy;
the choice between these procedures depends on the size of the cervical
lesion, the clinical team’s preference and the degree of suspicion.
• The indication for conisation decreases as the pregnancy progresses because
of the risk and morbidity of this procedure, including bleeding in 4–15% of
cases, pregnancy loss, premature delivery or premature rupture of
membranes, which increases with gestational stage.
4/30/20 Elbohoty
71
IB1 or more and suitable for radical surgery
• In women diagnosed with stage I B1 cervical cancer at a later stage in their
pregnancies
• delivery should be by caesarean section once viability has been achieved,
immediately followed by radical hysterectomy and pelvic lymphadenectomy by a
gynaecological oncologist.
• Obstetricians, neonatologists and gynaecological oncologists should work
together closely when dealing with such women to optimise outcomes for both
the woman and her baby.
4/30/20 Elbohoty
72
37. 8/9/1441
37
More advanced cervical cancer
• Standard management is with chemo- radiotherapy. Post delivery or
termination of pregnancy
4/30/20 Elbohoty 73
73
Prognosis
• Generally the prognoses of squamous cell carcinoma, adenocarcinoma or
adenosquamous carcinomas are the same.
• However, rarer subtypes, such as small-cell carcinoma hold a poorer prognosis,
as in nonpregnant women.
• In cases of aggressive disease with relatively poorer prognosis, termination of
pregnancy should be considered and the woman should be treated following
termination to optimise the outcome for the patient.
4/30/20 Elbohoty
74
38. 8/9/1441
38
Follow up
• Postpartum follow-up is the same as for nonpregnant women. In women who
have undergone hysterectomy or chemoradiotherapy, this involves general
examination, examination for peripheral lymphadenopathy, and abdominal and
vaginal examination. In women treated with LLETZ or conisation, follow-up is
cytological along with examination as described above, and is often best
performed in the colposcopy setting because of difficulties in obtaining adequate
cervical cytology samples.
• Women treated with trachelectomy should also be followed-up in the
colposcopy setting with clinical examination, cytology and MRI examinations in
accordance with the protocol of the treating cancer centre.
• It should be remembered that the majority of women with cervical cancer have a
good prognosis, with 5-year survival rates in women with stage I disease
exceeding 95%
4/30/20 Elbohoty
75
4/30/20 Elbohoty
The risks to the mother of continuing the pregnancy
need to be balanced carefully against the risks of
preterm delivery.
In general terms, treatment for the cervical cancer
should proceed without delay if a diagnosis is made
before 20 weeks of gestation.
Similarly, beyond 28 weeks, fetal viability is more
assured and following antenatal corticosteroids an early
delivery can be performed.
The difficulty, therefore, lies between 20 and 28 weeks of
gestation, where the prognosis may be worsened in
stage Ib1 disease when treatment is delayed.
76
76
39. 8/9/1441
39
A classical caesarean section followed by
•A radical hysterectomy and pelvic lymphadenectomy
in early stages
•A radical chemoradiotherapy in advanced stages
Radiotherapy will usually result in miscarriage if used in
the first trimester, while termination (medical or surgical)
will be required in the second trimester prior to
radiotherapy.
4/30/20 Elbohoty 77
77
Imaging in the follow-up of patients with cervical cancer
• MRI
• There is no routine imaging following radical hysterectomy.
• In patients who have undergone fertility-sparing radical trachelectomy, routine clinical
surveillance is undertaken.
• In patients treated with primary chemoradiotherapy, MRI is used to monitor response
during and at the completion of treatment. For example, at some centres, MRIs are
performed at 3 monthly intervals for 1 year or until complete radiological response is
seen. Decrease in tumour volume can be seen as early as 2 months after treatment and
predicts a good prognosis. If the patient is found to have a complete response after
chemoradiotherapy, no further routine imaging is necessary.
• In the case of tumour recurrence, MRI is superior in distinguishing fibrosis from active
disease. Sometimes, in the first 6 months after treatment, the appearances can be
indeterminate.
• CT and PET/CT imaging
• If, on MRI imaging, a small area of residual tumour is detected at the completion of
treatment, there is a window of opportunity to offer exenterative surgery. These patients
should then undergo PET/CT imaging prior to surgery to exclude lymphadenopathy and
distant spread of disease.4/30/20 Elbohoty 78
78
