Surgical Intervention in Surgical Intervention in Gynaecological CancerGynaecological Cancer

Alex J CrandonAlex J CrandonMB BS PhDMB BS PhD

FRCOG FRANZCOG CGOFRCOG FRANZCOG CGO

Gynaecological Oncology SurgeonGynaecological Oncology SurgeonBrisbane Private Hospital/Mater HospitalBrisbane Private Hospital/Mater Hospital

DirectorDirectorQld Centre for Gynaecological CancerQld Centre for Gynaecological Cancer

Management of CancerManagement of Cancer

1.1. Make the diagnosis,Make the diagnosis,

2.2. Determine the distribution of disease,Determine the distribution of disease,

3.3. Ask: “What is the aim of treatment?”Ask: “What is the aim of treatment?”• Cure or palliationCure or palliation

4.4. What does the literature is/are the What does the literature is/are the best treatment option(s).best treatment option(s).

Treatment OptionsTreatment Options

SurgerySurgery ChemotherapyChemotherapy RadiotherapyRadiotherapy Some combination of aboveSome combination of above Doing nothing – the hardest option.Doing nothing – the hardest option.

Getting it RightGetting it RightDeterminants of survivalDeterminants of survival

SiteSite StageStage Tumour typeTumour type Tumour differentiationTumour differentiation Patient’s agePatient’s age Co-morbiditiesCo-morbidities ManagementManagement

Endometrial CancerEndometrial Cancer

Surgery is the primary treatment Surgery is the primary treatment modalitymodality

Abdominal total hysterectomy & Abdominal total hysterectomy & bilateral salpingo-oophorectomybilateral salpingo-oophorectomy

Place of lymphadenectomy is still Place of lymphadenectomy is still controversialcontroversial

Some patients require adjuvant therapySome patients require adjuvant therapy

Typical patientTypical patient ElderlyElderly ObeseObese HypertensiveHypertensive DiabeticDiabetic PostmenopausalPostmenopausal Decreased Decreased

mobilitymobility

ChallengesChallenges Surgical accessSurgical access Wound infectionWound infection Wound Wound

dehiscencedehiscence Venous thombo-Venous thombo-

embolismembolism Pressure areasPressure areas Anaesthetic Anaesthetic

complicationscomplications

Endometrial Cancer

LACE TrialLACE Trial

Laparoscopic Approach in Cancer Laparoscopic Approach in Cancer of the Endometriumof the Endometrium TLH & BSO +/- lymphadenectomyTLH & BSO +/- lymphadenectomy

Easier surgical accessEasier surgical access Shorter in-patient stayShorter in-patient stay Less wound infectionsLess wound infections Less problems with diabetesLess problems with diabetes Ambulation increasedAmbulation increased

Cervical CancerCervical CancerRole of surgeryRole of surgery

DiagnosisDiagnosis Biopsy – punch, wedge, coneBiopsy – punch, wedge, cone

Surgical stagingSurgical staging Better evaluation of diseaseBetter evaluation of disease Effect on survival not establishedEffect on survival not established

Primary treatmentPrimary treatment Salvage treatmentSalvage treatment

Cervical Cancer Cervical Cancer EvaluationEvaluation

Formal FIGO staging procedureFormal FIGO staging procedure Examination under anaesthesiaExamination under anaesthesia Adequate tissue sample (biopsy)Adequate tissue sample (biopsy) CystoscopyCystoscopy Occasionally proctoscopy/sigmoidoscopyOccasionally proctoscopy/sigmoidoscopy

Cervical CancerCervical Cancer

Primary treatment depends on multiple Primary treatment depends on multiple factorsfactors Stage of diseaseStage of disease Age & parity of patientAge & parity of patient General healthGeneral health

Early stage disease – 1a1 to 1b1 by primary Early stage disease – 1a1 to 1b1 by primary surgerysurgery

Later stage disease – 1b2 to 3b by chemo-Later stage disease – 1b2 to 3b by chemo-radiationradiation

Stage 4 needs to be individualisedStage 4 needs to be individualised

Cervical Cancer – Stage Cervical Cancer – Stage 1a1a

Stage 1a1 – Stage 1a1 – invasion invasion ≤3mm ≤3mm deep & ≤ 7mm deep & ≤ 7mm laterallylaterally

Treatment Treatment optionsoptions ConisationConisation Total Total

hysterectomyhysterectomy Ovarian Ovarian

conservation in conservation in young patientsyoung patients

Stage 1a2 – Stage 1a2 – invasion >3 invasion >3 ≤5≤5mm mm deep & deep & ≤7mm ≤7mm horizontallyhorizontally

Treatment optionsTreatment options ConisationConisation Total hysterectomyTotal hysterectomy Ovarian Ovarian

conservation in conservation in young patientsyoung patients

Lymphadenectomy Lymphadenectomy if LVSI +veif LVSI +ve

Cervical Cancer - Stage Cervical Cancer - Stage 1b1b

Stage 1b1 – visible Stage 1b1 – visible lesion lesion ≤≤4cm 4cm confined to cervixconfined to cervix

Treatment optionsTreatment options Radical Radical

hysterectomy + hysterectomy + lymphadenectomylymphadenectomy

Chemo-radiationChemo-radiation Special casesSpecial cases

Radical Radical trachelectomytrachelectomy

Stage 1b2 – Stage 1b2 – Visible lesion Visible lesion >4cm confined >4cm confined to cervixto cervix

Treatment Treatment optionsoptions Chemo-radiationChemo-radiation

Cervical CancerCervical CancerSurgery for recurrenceSurgery for recurrence

Attempted salvage back to cureAttempted salvage back to cure Pelvic exenteration in highly Pelvic exenteration in highly

selected patientsselected patients PalliativePalliative

Management of simple or complex Management of simple or complex fistulasfistulas

Defunctioning stomasDefunctioning stomas ColpocliesisColpocliesis

Cervical Cancer with Ureteric Cervical Cancer with Ureteric ObstructionObstruction

In primary untreated diseaseIn primary untreated disease Ascending ureteric stentsAscending ureteric stents Try to avoid percutaneous Try to avoid percutaneous

nephrostomynephrostomy In recurrent diseaseIn recurrent disease

Maybe attempt ascending stentsMaybe attempt ascending stents NeverNever use percutaneous nephrostomy use percutaneous nephrostomy

Cervical CancerCervical CancerPsychosocial IssuesPsychosocial Issues

Vaginal shortening – 4 -100%Vaginal shortening – 4 -100% Decreased vaginal lubrication – 17 – 58%Decreased vaginal lubrication – 17 – 58% Marital attrition is increasedMarital attrition is increased

May uncover many dysfunctional May uncover many dysfunctional relationshipsrelationships

Insufficient support servicesInsufficient support services

Ovarian CancerOvarian Cancer

Most present with advanced diseaseMost present with advanced disease 75-80% have stage 3-4 disease at 75-80% have stage 3-4 disease at

presentationpresentation Surgery is the primary form of Surgery is the primary form of

treatment followed by chemotherapytreatment followed by chemotherapy Cytoreduction is of paramount Cytoreduction is of paramount

importanceimportance

Stage IIIC EOC Stage IIIC EOC Residual Disease –v- Disease Specific Residual Disease –v- Disease Specific

SurvivalSurvival

100

90

80

70

60

50

40

30

20

10

0

% S

UR

VIV

AL

12 24 36 48 60 MONTHS

47% (135-32) Nil

95% CI MedianNil 135 102 80 62 45 32 37, 57[ ] 57 Mths

26% (227-26) <1cm

95% CI Median

<1cm 227 192 118 75 38 26 19, 33[ ] 32 Mths

16% (170-10) 1+cm

95% CI Median

1+cm 170 115 62 39 22 10 8, 23[ ] 23 Mths

Ovary 3c - Residual disease

Stage IIIC EOCStage IIIC EOCResidual Disease and Relapse Free Residual Disease and Relapse Free

SurvivalSurvival

100

90

80

70

60

50

40

30

20

10

0

% R

ELA

PS

E F

RE

E

12 24 36 48 60 MONTHS

27% (135-18) Nil

95% CI MedianNil 135 89 47 31 21 18 18, 36[ ] 23 Mths

13% (227-14) <1cm

95% CI Median

<1cm 227 145 51 31 19 14 8, 18[ ] 13 Mths

6% (170-3) 1+cm

95% CI Median

1+cm 170 82 21 12 5 3 1, 10[ ] 12 Mths

Ovary 3c - Residual disease

ConclusionsConclusions

Nil residuum have a statistically Nil residuum have a statistically significantly better overall and significantly better overall and relapse free 5 year survival, relapse free 5 year survival, p<0.001p<0.001

Once the residuum gets to Once the residuum gets to ≥1cm ≥1cm then it doesn’t matter how much then it doesn’t matter how much residuum you leave behindresiduum you leave behind

The proportion left with nil The proportion left with nil residuum needs to be increasedresiduum needs to be increased

Management of Advanced Management of Advanced DiseaseDisease

Pelvic & omental disease well Pelvic & omental disease well managedmanaged

Tendency to leave paracolic, Tendency to leave paracolic, abdominal wall, sub-abdominal wall, sub-diaphragmatic, retro-hepatic and diaphragmatic, retro-hepatic and para-splenic disease to be dealt para-splenic disease to be dealt with by chemotherapywith by chemotherapy

This last decision is obviously This last decision is obviously detrimental to patient survivaldetrimental to patient survival

Peritonectomy Peritonectomy MethodologyMethodology

Very careful selection of patients Very careful selection of patients for this procedurefor this procedure Relatively fit and wellRelatively fit and well Three day pre-operative inpatient Three day pre-operative inpatient

assessment by anaesthetist, assessment by anaesthetist, intensivist, medical oncologist & intensivist, medical oncologist & surgeonsurgeon

Reservations involving 2 or more Reservations involving 2 or more and the patient doesn’t get doneand the patient doesn’t get done

Peritonectomy AdmissionPeritonectomy Admission

Admitted at least 1 day prior to Admitted at least 1 day prior to surgerysurgery

High nitrogen low residue diet High nitrogen low residue diet continued (started at home)continued (started at home)

Full bowel prep with IV infusion Full bowel prep with IV infusion runningrunning

Repeat FBC, Biochem & LFT’s, Repeat FBC, Biochem & LFT’s, MagnesiumMagnesium

Possible stoma sites markedPossible stoma sites marked

Peritonectomy Peritonectomy PositioningPositioning

Peritonectomy Peritonectomy MethodologyMethodology

LongLong midline incision – assess and decide if midline incision – assess and decide if proceed to peritonectomyproceed to peritonectomy

Total omentectomy up to spleen and splenic Total omentectomy up to spleen and splenic flexure +/- splenectomyflexure +/- splenectomy

Excise falciform ligament and ligamentum Excise falciform ligament and ligamentum teres, mobilise liver and do right upper teres, mobilise liver and do right upper quadrant; left upper quadrant; abdominal quadrant; left upper quadrant; abdominal wall and paracolic gutters; pelvis with wall and paracolic gutters; pelvis with retrograde hysterectomy, BSO, pelvic retrograde hysterectomy, BSO, pelvic peritonectomy +/- low restorative rectal peritonectomy +/- low restorative rectal resection; finish mesentry & small bowel.resection; finish mesentry & small bowel.

Insertion naso-jejunal feeding tubeInsertion naso-jejunal feeding tube All surgery performed by QCGC staffAll surgery performed by QCGC staff

PeritonectomyPeritonectomyExtent of SurgeryExtent of Surgery

10 thoracotomies – 6 ICC’s10 thoracotomies – 6 ICC’s 8 significant diaphragmatic resections8 significant diaphragmatic resections 7 subsegmental liver resections7 subsegmental liver resections 3 cholecystectomies3 cholecystectomies 6 splenectomies, 2 distal 6 splenectomies, 2 distal

pancreatectomiespancreatectomies 3 partial cystectomies, 1 ureteric 3 partial cystectomies, 1 ureteric

implantationimplantation 6 GIT resections; 4 small, 4 large & 1 6 GIT resections; 4 small, 4 large & 1

partial antrectomypartial antrectomy 5 HIPC, 4 post operative IPC.5 HIPC, 4 post operative IPC.

Post Operative Post Operative ManagementManagement

All patients admitted to ICU All patients admitted to ICU ventilatedventilated

Ventilatory support for 3 to 8 daysVentilatory support for 3 to 8 days ICU stay for 5 to 10 daysICU stay for 5 to 10 days Post-operative hospital stay 16 to 45 Post-operative hospital stay 16 to 45

daysdays Naso-jejunal feeding started soon Naso-jejunal feeding started soon

after admission to ICUafter admission to ICU

Lessons LearntLessons Learnt

Requires a real team approachRequires a real team approach Advantages in having an anaesthetist Advantages in having an anaesthetist

with cardiac/hepatobiliary experiencewith cardiac/hepatobiliary experience Extent of peritonectomy dependent on Extent of peritonectomy dependent on

disease distribution & prior disease distribution & prior chemotherapychemotherapy

Liver mobilisation often uncovers covert Liver mobilisation often uncovers covert diseasedisease

Temperature control can be a problem – Temperature control can be a problem – use an air mattress circulating warm airuse an air mattress circulating warm air

Conclusion 1 from Conclusion 1 from PeritonectomiesPeritonectomies

Peritonectomy is a relatively Peritonectomy is a relatively safe proceduresafe procedure

Conclusion 2 from Conclusion 2 from PeritonectomiesPeritonectomies

If disease can be debulked to If disease can be debulked to 2cm then it can be debulked 2cm then it can be debulked to nil residuum but however to nil residuum but however long it takes to get to 2cm it long it takes to get to 2cm it will take 1 to 2 times as long will take 1 to 2 times as long again to get to nil residuum.again to get to nil residuum.

Conclusion 3 from Conclusion 3 from PeritonectomiesPeritonectomies

At laparotomy if initial assessment At laparotomy if initial assessment indicates that disease cannot be indicates that disease cannot be debulked to nil residuum then debulked to nil residuum then limited omentectomy only should be limited omentectomy only should be performed with a view to interval performed with a view to interval debulking if good response to debulking if good response to Chemo Chemo

On present experience modified On present experience modified peritonectomy is a feasible and peritonectomy is a feasible and viable procedure for advanced EO & viable procedure for advanced EO & PP carcinoma and should become PP carcinoma and should become the standard of carethe standard of care

Following PeritonectomyFollowing Peritonectomy

Adjuvant chemotherapyAdjuvant chemotherapy Follow-upFollow-up QOL takes months to recoverQOL takes months to recover Psychosocial support is important Psychosocial support is important

after such ultra-radical surgeryafter such ultra-radical surgery

Vulval CancerVulval CancerClinical FeaturesClinical Features

Vulval lump or massVulval lump or mass Often long history of pruritisOften long history of pruritis Increasing incidence of warty Increasing incidence of warty

carcinomascarcinomas Also assess vagina and cervix – Also assess vagina and cervix –

common sites for HPV related common sites for HPV related diseasedisease

Vulval CancerVulval CancerPlace of surgeryPlace of surgery

DiagnosisDiagnosis Wedge biopsy or good core biopsyWedge biopsy or good core biopsy

Primary TreatmentPrimary Treatment Primary vulval sitePrimary vulval site Regional nodal diseaseRegional nodal disease Reconstructive Reconstructive

Important for body imageImportant for body image Improves post-operative outcomeImproves post-operative outcome Better functional outcomeBetter functional outcome

Vulval CancerVulval CancerOld Radical VulvectomyOld Radical Vulvectomy

ChallengesChallenges Provide adequate Provide adequate

surgical excision surgical excision without without excessive excessive morbiditymorbidity

Vulval CancerVulval CancerNew ApproachNew Approach

Wide local excisionWide local excision Provide minimum of 10mm clear Provide minimum of 10mm clear

margin in fixed specimenmargin in fixed specimen Remove to depth of deep fasciaRemove to depth of deep fascia Node treatment if invasion >1mmNode treatment if invasion >1mm

Separate groin node managementSeparate groin node management Sentinel node identificationSentinel node identification Groin node dissectionGroin node dissection

Vulvectomy Vulvectomy Nursing CareNursing Care

Easily becomes infectedEasily becomes infected Bed rest for 3 to 5 days to allow Bed rest for 3 to 5 days to allow

for healingfor healing Twice daily perineal toilet and Twice daily perineal toilet and

keep dry for first 5 dayskeep dry for first 5 days IDC to until ambulant and IDC to until ambulant and

healing establishedhealing established

VulvectomyVulvectomyComplicationsComplications

EarlyEarly Wound infection Wound infection

& breakdown& breakdown Urinary tract Urinary tract

infectioninfection DVT/PEDVT/PE Seroma/cellulitis Seroma/cellulitis

especially of especially of groingroin

LateLate Chronic leg Chronic leg

lymphoedemalymphoedema Recurrent Recurrent

lymphangitislymphangitis Stress Stress

incontinenceincontinence ProlapseProlapse Introital stenosisIntroital stenosis OsteomyelitisOsteomyelitis FistulaFistula

Vaginal CancerVaginal Cancer

Surgery usually limited to Surgery usually limited to establishing the diagnosis.establishing the diagnosis.

Generally treated by Generally treated by radiotherapy +/- chemotherapyradiotherapy +/- chemotherapy

Palliative SurgeryPalliative Surgery

GIT obstructionGIT obstruction Stoma formationStoma formation

Ureteric obstructionUreteric obstruction Don’tDon’t rush into percutaneous rush into percutaneous

ureterostomyureterostomy Fistula formationFistula formation

Genital tract (vesico-vaginal / Genital tract (vesico-vaginal / entero-vaginal)entero-vaginal)

Entero-cutaneousEntero-cutaneous