In the name of God

Isfahan medical school

Shahnaz Aram MD

Recurrent cervical cancerRecurrent cervical cancer►Within 6 months after completion of Within 6 months after completion of primary therapy = persistentprimary therapy = persistent►After 6 months = recurrentAfter 6 months = recurrent►1/3 patients experience tumor 1/3 patients experience tumor recurrencerecurrence►Symptoms depend on the site and Symptoms depend on the site and extent of tumorextent of tumor►early central pelvic recurrenceearly central pelvic recurrence Vaginal discharge and bleedingVaginal discharge and bleeding

►Widespread metastasis Widespread metastasis malaise, malaise, loss of appetite, general symptoms loss of appetite, general symptoms

►Lateral pelvis recurrence has late Lateral pelvis recurrence has late manifestationsmanifestations

►Unilateral leg edema is due to Unilateral leg edema is due to lymphatic fibrosis after operation or lymphatic fibrosis after operation or radiationradiation

►Urethral obstruction, unilateral or Urethral obstruction, unilateral or bilateral bilateral decrease in kidney decrease in kidney function , low back painfunction , low back pain

Patients treated for cancer

Evaluated: Every 3 months for the first year Every 4 months in second year Every 6 months in third year Yearly thereafter More frequently examination if abnormal symptom Examination consists of vaginal and cervical

cytology

• Complete physical and pelvic examination

• Chest X-Ray annually

• IVP, abdominal pelvic CT scan annually in the first 2 years

• with recurrence renal function test

• Ureter fibrosis occurs more than 5 years after radiation

• Blood test for scc Ag, if Ag increased suspected recurrence

Pelvic recurrence Half of recurrence in pelvis Clinical assessment CT, TVS Adenocarcinoma distant site

( lung, suprclavicular) Chemoradiation for local pelvic

recurrence and previous radiation Surgery (complication) Palliative chemotherapy

Treatment Treatment

Depends on Depends on

1- mode of primary therapy1- mode of primary therapy

2- site of recurrence2- site of recurrence If in pelvis after radiation , most If in pelvis after radiation , most

patients Exenterationpatients Exenteration TAH is inadequate TAH is inadequate Occasional patients may be salvaged Occasional patients may be salvaged

by radical hysterectomyby radical hysterectomy

If pelvic recurrence after surgery

radiation ( External beam, vaginal

ovoid )

Surgical therapy for post irradiation is limited to patients with central pelvic disease

Small volume disease

Urinary complications 30-50%

Preoperative Evaluation

Patient selection Screen for metastasis Physical examination Careful palpation of lymph nodes FNA cytology if suspicious Random biopsy Supraclavicular ( not routine) CT scan of lungs if chest normal Abdominal pelvic CT (liver, para aortic ) CT directed FNA cytology

Exploratory laparatomyExploratory laparatomy

Parametrial Biopsy ( fibrosis)Parametrial Biopsy ( fibrosis) Bowel preparationBowel preparation Parenteral nutritionParenteral nutrition Prophylaxy for DVTProphylaxy for DVT Surgical mortality increases with ageSurgical mortality increases with age > 70?> 70? Surgical mortality < 10%Surgical mortality < 10% Mortality due to Mortality due to hemorrhage, pulmonary hemorrhage, pulmonary

thromboembolism, sepsisthromboembolism, sepsis Fistula 30-40% mortalityFistula 30-40% mortality

Pelvic ExenterationPelvic Exenteration

Contraindicated surgery ifContraindicated surgery if 1- unilateral leg edema1- unilateral leg edema 2- sciatic pain2- sciatic pain 3- urethral obstruction3- urethral obstruction Exenteration if central pelvic recurrenceExenteration if central pelvic recurrence 25% of patients are candidate for Exenteration25% of patients are candidate for Exenteration Exenteration is not performed for Exenteration is not performed for palliativepalliative Before Exenteration metastasis must be ruled Before Exenteration metastasis must be ruled

out by lymph node biopsy, frozen section, out by lymph node biopsy, frozen section, operative marginoperative margin

ExenterationExenteration 1- anterior1- anterior

2- posterior2- posterior

3- total3- total After total Exenteration After total Exenteration new pelvic floor new pelvic floor Left gastrioepiploic art release and Left gastrioepiploic art release and

omentom replacementomentom replacement Supra levator Exentraation (if 1/3 upper is Supra levator Exentraation (if 1/3 upper is

involved and frozen section of the lower involved and frozen section of the lower pelvis is negative )pelvis is negative )

5 year survival after Exenteration is 45-61%5 year survival after Exenteration is 45-61%

Non-pelvic recurrenceNon-pelvic recurrence

Recurrence outside of the pelvis Recurrence outside of the pelvis Treated with radiation, operation, Treated with radiation, operation,

chemotherapychemotherapy Local recurrence with radiationLocal recurrence with radiation Resection of the metastasis is rarely done Resection of the metastasis is rarely done

unless unless (local, 3-4 years after primary (local, 3-4 years after primary therapy)therapy)

General distant metastasis , no cure with General distant metastasis , no cure with local excisionlocal excision

Radiation re-treatmentIn suboptimal incomplete primary therapyCurative dose ( risk for bladder, rectum)Insertion multiple interstitial radiation source in

local recurrenceFor curable patient, Exenteration is betterRadiotherapy re-treatment (Palliative)Radiotherapy re-treatment in Locally

metastatic lesions indicated if 1- painful bony metastasis 2- CNS lesion 3- severe urologic or vena caval obstruction

Chemotherapy Chemotherapy Palliative Palliative For extra-pelvic metastasisFor extra-pelvic metastasis Relief of symptomsRelief of symptoms Prolongation of lifeProlongation of life Complete response is unusualComplete response is unusual Chemotherapy for small cell carcinoma of cervixChemotherapy for small cell carcinoma of cervix Unresectable pelvic recurrenceUnresectable pelvic recurrence General limited for lung metastasisGeneral limited for lung metastasis For a distant metastasisFor a distant metastasis Cisplatin = most clinical responseCisplatin = most clinical response Duration of response is 4-6 monthsDuration of response is 4-6 months 2 cases more than 5 years2 cases more than 5 years Chemoradiation Chemoradiation 1- sensitized of cervical cancer cells1- sensitized of cervical cancer cells 2- eliminate microscopic systemic metastasis2- eliminate microscopic systemic metastasis GOG cisplatin or cisplatin + paclitaxelGOG cisplatin or cisplatin + paclitaxel

Prognosis

• After anterior Exenteration 30-60% five year survival

• After total Exenteration 20-4-% • Mortality increase if 1- size of recurrence > 3cm2- bladder invasion3- positive pelvic lymph node 4-Recurrence after one year after radiation5-Peritoneal diseaseFive year survival if positive lymph node = 5%