evolution of the surgical management of cervical … querleu evolution... · t1b1/t2a mri / (us) ln...
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EVOLUTION OF THE SURGICAL MANAGEMENT OF
CERVICAL CANCER
Denis Querleu
Institut Bergonié Regional Cancer Center,
Bordeaux, France
Lead Group Log
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Roles of surgery
1. Surgicalmanagement
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2.1 Staging(early)
Roles of surgery
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2.2 Staging(advanced)
Roles of surgery
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New ESGO-ESTRO-ESP Guidelines on Cervical Cancer Management
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ESGO SOPs
• Step 1 - Nomination of multidisciplinary international development group
• Step 2 - Identification of scientific evidence
• Step 3 - Formulation of guidelines
• Step 4 - External evaluation of the guidelines - International review
• Step 5 - Integration of international reviewers´ comments
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ESGO Guidelines
• Collaboration with other leading European societies (ESMO, ESTRO, ESP, SIOPe)
• Multidisciplinary panels of a total of over 100 renowned experts involved in working groups over the past two years
• Over 300 international reviewers from 61 countries involved in the review (incl. patients) and evaluation
Special thanks to all contributors!!
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General statement
Treatment planning should be made on a multidisciplinary basis (generally at a tumor board meeting) and based upon the comprehensive and precise knowledge of prognostic and predictive factors for oncological outcome, morbidity and quality of life.
Patients should be carefully counseled on the suggested treatment plan, and potential alternatives, including risks and benefits of all options.
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Clinical staging
Patients with cervical cancer should be staged
according to the TNM classification
based on a correlation of various diagnostic modalities (integrating physical examination, imaging and pathology)
the method i.e. clinical (c), imaging (i)
and or pathological (p) should be recorded
MRI or specialized US
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T1a
T1a
Conisation
Margins negative Margins positive
(except for preinvasive ectocervix)
Re-conisation
Final pathology
T1a1 / T1a2
Diagnosisshould be basedon a conisationspecimen
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T1a1
LVSI neg. LVSI pos.
Surveillance Surveillance SLN
LN stagingis not indicated
Conisation can be considered definitive
T1a
LN stagingcan beconsidered; SLN isadequate
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T1a2
LVSI neg. LVSI pos.
± SLN ± simple hyst. SLN ± simple hyst.
LN stagingcan be considered; SLN is acceptable
T1a
Conisationor SH is anadequatetreatment
LN stagingshould beperformed; SLN isadequate
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T1b1/T2a1
Treatment strategy should aim for the avoidance of
combining radical surgery and radiotherapy due to the
highest morbidity after combined treatment.
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Radical surgery ORFertility sparing surgery
LN +
Adjuvant radiotherapy
T1b1/T2a1
Old process
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Radical surgery ORFertility sparing surgery
LN +
Adjuvant radiotherapy
SLN
Radical surgery Primary radiotherapyOR Fertility sparing surgery
T1b1/T2a1
New process
Neg. Pos.
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Role of radiologic assessment
T1b1/T2a
MRI / (US)
LN neg. LN pos.
Surgery RT CRT
± PALND
PALND, at least up to IMA, may be considered in ptswith negative PALN.
In pts withunequivocallyinvolved pelvicLN, definitiveCRT isrecommended
T1b1/T2a1
Radical surgery by a gynecologic oncologist is thepreferred modality (MIS)
Definitive RT including BRT represents efficientalternativetreatment.
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Surgical process
SLN (LN)
FS
(S)LN neg or not done LN pos (MAC or MIC)
PLND + tailored RH RH abandoned
No further LN dissection±PALND
CRT
Intraoperativeassessment of LN isrecommended (SLN / LN / suspicious LN)
LN assessmentshould be performedas the 1st step. SLN isstronglyrecommended.
T1b1/T2a1
PALND, at least up to IMA, may be considered in pts with negative PALN.
According to riskstratification
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Inferiorhypogastric plexus
Left hemicervixand paracervix
Deep uterine vein
Surgical anatomy of the paracervix
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Tailoring surgery
Type of RH Lateral parametrium Ventral parametrium Dorsal parametrium
Type A Halfway between cervix and ureter
Minimal Minimal
Type B1 At the ureteral bed Partial excision of thevesicouterine lig
Partial excision of therecto-uterine/-vaginal lig
Type B2 B1 + paracervical LND B1 B1
Type C1 At the iliac vesselstransversally, at the
uterine vein horizontally
Excision of thevesicouterine lig (cranial
to the ureter)
At the rectum(hypogastric nerve is
spared)
Type C2 C1 + caudal part At the bladder (incl. vesico-vaginal lig)
At the sacrum
Querleu-Morrow classification (update 2017)
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Classification of radical hysterectomies
/trachelectomies
Removal of medial
paracervix Paracervical lymph node dissection
A
B1
B2+
Ureter
Uterine artery
C1
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Tailoring surgery
Risk group Tumor size LVSI Stromalinvasion
Type ofrad hyst
LR 2 cm Neg Inner 1/3 B1 (A)
IR ≥ 2 cm Neg Any B2 (C1)
2 cm Pos Any
HR ≥ 2 cm Pos Any C1 (C2)
Risk groups according to prognostic factors and suggested type of radical hysterectomy
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Post surgical process
Final histology
LN neg AND LN pos OR
Parametria neg AND Parametria pos OR
Vaginal margins neg Vaginal margins pos
Combination of risk factors Adjuvant (C)RT(LVSI, Tumor size, Stromal invasion)
FU No Yes ± Adjuvant RT
T1b1/T2a1
Adjuvant RT should be considered.
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Final histology
LN neg AND
Parametria neg AND
Vaginal margins neg
Combination of risk factors (LVSI, Tumor size, Stromal invasion)
FU NO Yes ± Adjuvant RT
Adjuvant RT should be considered.
When an adequatetype of radicalhysterectomy has been performed, observation is analternativeapproach…
Post surgical processT1b1/T2a1
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Back to presurgicaldecision
Final histology
LN neg AND
Parametria neg AND
Vaginal margins neg
Combination of risk factors (LVSI, Tumor size, Stromal invasion)
FU NO Yes ± Adjuvant RT
If a combination of risk factors is known at diagnosis, which would require an adjuvant treatment, definitive radiochemotherapy and brachytherapy can be considered without previous radical pelvic surgery.
T1b1/T2a1
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Fertility sparing
Candidate selection Squamous cell / usual type (HPV related) adenocarcinoma
Largest diameter ≤ 2 cm
LN staging (SLN / LN)
FS
LN neg. LN pos.
Identical principles
FST in patients withtumors 2cm isconsidered anexperimentalapproach.
FST should not be recommended forrare histologicalsubtypes includingneuroendocrine ca and unusual-type of adenocarcinomas.
Pelvic LN stagingshould always bethe 1st step.
T1b1/T2a1
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• Treatment strategy should aim for avoiding the combination of
radical surgery and postoperative external radiotherapy, due to the
significant increase of morbidity and no evident impact on survival
(grade C)
• Definitive platinum-based chemoradiotherapy and
brachytherapy is the preferred treatment) (grade A)
• Paraaortic (at least up to inferior mesenteric artery) lymph node
dissection may be considered before chemoradiotherapy and
brachytherapy. Pelvic lymph node dissection is not required (grade
C)
• Radical surgery is an alternative option in stage IB2, in particular in
patients without negative risk factors (combinations of tumour size, LVSI, and/or depth of stromal invasion).
T > 1b1
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ESGO Pocket Guidelines Series
Available at ESGO booth
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ESGO ALG APP
Cervical Cancer Guide
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شكراً على اهتمامكم Thank you for your attention
Merci pour votre attention