Surgical management of carcinoma of the cervix

Surgical management of carcinoma of the cervix H. J.

H. A.

London,

ALLEN,

M.D

COLLINS.

M.D.

Ontario.

Cnnadu

Three hundred andfifty-two cases oj carcinoma of the cervix which required some surgical procedure are re~Gewed. In Group I (pimary treated), the lymph nodes were positizle in 9 per cent with Stage I and 45 per cent with Stage II disease. This group had an 88 prr cant jive-year ,surviz~al rate; patients with positive lymph nodes had a 60 per crnt tw-year survival rate. One or more surgical complications occurred in 16.5 per cent of‘ patients treated for recurrent disease. Tfiejue-year survival rate in patients treated jbr recurrent disease ulas 35 per cent. The Schauta-Amreich procedure is being used more rommonl~~ for poor-risk patients with recurrent disease conjinrd to the cervix or with superjicial raginal inzwlz~ement (AM. J. OBSTET. GYNECOL. 127: 741 1 1977.)

carcinoma in situ and patients with persistent radiation necrosis that did not respond to local and parenteral medical management. Laparotomy only was performed on 28 patients in whom the disease had advanced to the point that definitive operation could not be carried out wjth any expectation of long-term survival (for example, where high periaortic nodes were positive or a mass was fixed to the pelvic wall and could not be resected). As primary treatment, radical hysterectomy and pelvic node dissection were performed in 134 patients, and hysterectomy only was performed for microinvasion in 18 patients; finally, exenteration as the primary method of treatment was performed in three, for a total of 155 patients. The indications for primary surgical treatment are shown in Table I. Carcinoma of the cervix is usually found in premenopausal patients, and ovarian function is an important consideration. Metastases to the ovary are very rare in early disease, especially in the patient not treated with radiation, where lymphatic channels have not been fibrosed and obstructed to encourage collateral lymphatic drainage. There have been no recurrences in the ovary in the 86 patients who were treated with preservation of one or both ovaries and who were followed up for two or more years. Chronic infection associated with radiation may result in an exacerbation of the pelvic inflammatory process, resulting in pelvic cellulitis. occasionally with pelvic thrombophlebitis or abscess formation. Pelvic fibrosis with pain and dyspareunia for the remainder of the patient’s life can result. Any chronic pelvic inflammation is an indication for surgical management of carcinoma of the cervix.

to be the usual method of treatment for carcinoma of the cervix in the Ontario Cancer Foundation, London Clinic, and in all of Canada. However, surgical treatment seems to have a growing place in the various aspects of management of this disease. There are indications for operation as the primary treatment as well as for treatment for recurrent disease, management of complications, and treatment planning. RADIATION

CONTINUES

Material Three hundred and fifty-two cases of carcinoma of the cervix that required some surgical intervention during the past 15 years are reviewed. All operations were performed by one of the authors. Operation was the primary treatment for 155 patients, and for 118 operation was for treatment of recurrent disease. Radioresistant tumor was the indication in five patients, and 11 had palliative hysterectomy, usually for hematometria associated with recurring abdominal pain and vaginal bleeding in which the uterus itself was resectable without cutting through gross tumor but distant metastases were present. Thirty-five patients were operated upon for negative or noninvasive disease; these included patients with recurrence in the vaginal vault or cervix diagnosed as

From the Department oj Obstetrzcs and Gynecology, l’ictoria Hospital, University of Westwn Ontario, and the Ontario Cancer Foundation, London Clinic. Prrrcnted at the Thirty-second Annual Meeting of the Sorwty c$ Obstetricians and Gynaecologists of Canada, Toronto. Ontario, Canada, June 8-12, 1976. Rep&t Loudon,

rcquexts: Ontario,

Dr. H. H. A&n, 111 Waterloo Canada, N&B 2M4.

St.,

741

742

Allen and Collins

Table

I. Indications

for

primary

surgical

treatment

When

the

bladder, is treated

Age

68

Pelvic intlammatory disease Pregnant or postp&tum Difficult to radiate Associated pelvic tumors Microinvasion Refused radiation Mucus-secreting tumor Syphilis Bladder or bowel invasion Combined indication

22 13 Ii

or

investigation

and

of primary

surgical

the

past

had

four

There

155 patients

and 1

years were

complications

are

pregnant

patient

patient

with

advanced

or

Operation a very

radiation

and

There

were

cervix.

were

disease

be

than

tainly

true.

considered

Some

disease

is too

resection.

such

for

narrow

very

obese

Good

vault

possible

patient

surgical

radiotherapy,

patients

vaginal is not

is indicated

suitable

for

such

is not

part

of North

very

similar

effect

of

necrosis

resectablr.

ing

where the

radioresistant,

is cer-

of

poorlv the

tbr

removal

a common

to that

of the normally

surgical The

of postradiation at a markedly

expect.

indication

endarteritis

is exaggerated area

of other

definitive the disease

pelvic surgical is early

treatment.

America.

radiation

out

patients and lower

in our

of syphilis so that

the

may

result

in

dose

than

one

ago,

and

t\so

patients

over

dose.

disease

in this

two

an abso-

central and,

the patient

\;omiting

is

and for

portion usual the are

surgically. abscess

usually

fl-om uterus o~‘ca-

discontinuation

discontinuing

can

somewhat

growing

treatment

is treated

diarrhea,

indications

cerris

remove

and

Only operation. tumor

\ve

therapy,

tumor

of‘the

than

radiation

the

barrel-shaped

distance

to require

cervix lOllo\~-

portion

actively

Therefore,

the

study.

thereforr,

the outer,

enough

of

following

the large The

at 2-I

is surgicalI)

treatment.

veal-s

third

dead

survived

disease

radiation

is at a greater source.

and

were

up to six months

despite

\vho

one

thirds

carcinoma

serious

Nausea

cervix

of malignancy

to radiate

proctitis,

of 96

radioresistant

oxygenated

been

carcinoma 11.e reviewed

patients

four

if the

tumor

radiation

‘1 ” Approximately

recurrent

and

discc’r\ ix,

01‘ the

sionally

all

cctl~.

paticLnt\

recurrent

recurrent

years

following radiation. Complications during

fever, is

with

only

In five

radium

155

treatment,

regard

in a tumoricidal is

hyh-

no flstulas, 5 per

the are

operation

is alive

external

than

in

for

It is difficult

for

less

carcinoma

year:

to grow

patient

been

would

presence

is always

reverse

one

treatment.

one

where and

treatment and

who

13 paticntz,

a barrel-shaped

of

radiation.

define

as the

in

laparotom)-.

recurrent

indication

continued

it is usually best to carry at that time, providing

Syphilis

the

the

occur-

prophylactic

last 85 radical

operation

1 18 patients

M’e

lute

of

have

during

staging

of

the with

for

ar six months,

end

use

deaths

disease,

repeat dead

the

If operation tumors, treatment

to treat

associated

to surgical

or

in the poor

cervix unless

application

is difficult.

better

treating

\vas

(Table

by operation.

with

received the

rate operative

A number

patients

treatment

In the

there

complications

necrosis, the

advanced.

tented

radium

therapy

would

more

in

We prefer the

means

should

effective early

of

to be amenable

IIB

exhibit

problems

radiation.

by surgical

as Stage

and

with

of

carcinoma

pregnancy far

a number

1 adiin

none

the

cent.

series,

radioresistant

months. There

\\-ith

is preterred

16 complications

indications

ease,

13

no

primarily

Other

16

with

surgi-

or bladder

surgical

since

complication were

treated 5 1 1 I 2 I 1 2 1 I

complications patients

in this

the

There

h’o.

Thrombophlebitis Pulmonary embolus Bronchopneumonia Bowel obstruction Infection Bladder fistula Bowel fistula Lymphocyst Mismatched transfusion at operation Retroperitoneal hematoma

Total

glands preop~r;~-

On

thrttmbophlebitis,

8 per

terectomies

Complzcation

Total

periaortic

dissection

nocic

OI

patient

of laparotomy.

bowel

of primary

or approximately in

time

bowci

if’thr

demonstrated

at the

and

Complications II). Five patients heparin.

treatment

positive

no

are

the

Ctlinic

ring

II. Complications

result

Results

Total

Table

into

a c.rrtain

of the involved

hysterectomv

our

extended

If

metastases

cal removal cal

has

is almost

bv radiation.

distant

tive

disease

a fistula

of

Persistent

formation

ha\~c

treatment.

be controlled

with

medication. In whrr-e

patients gland

with Stage involvement

II

carcinoma of the crrvix is fairlv
Surgical management of cervical carcinoma

from 25 to 40 per cent, staging laparotomy can be performed to determine whether para-aortic nodes are positive and the necessity of extending the radiotherapy up the aorta. Radiation necrosis may occur six months to many years following treatment. In general, if ulceration and infection develop at the vault before two years have passed, recurrent carcinoma is the most probable diagnosis. Beyond two years, radiation necrosis is more probable, although this is not an absolute rule. Local and parenteral treatment with estrogens and antibiotics generally will be successful. Operation is considered only in cases where three months or more of medical management have failed. For recurrent carcinoma of the cervix, radical hysterectomy and node dissection alone were carried out in 63 patients, with some bladder resection in three others, bowel resection in five, and arterial resection in an additional four patients. Radical hysterectomy and node dissection were selected for the patients who had recurrence with central disease in the vaginal vault or in the cervix where it was possible to operate well outside the tumor without resection of the bowel or bladder. Vascular resection rarely can be considered for pelvic disease. In four patients the resection was extended into the pelvic wall to include part of the levator and ihopsoas muscle along with the external, internal, and common iliac arteries. An arterial prosthesis was used. Only one patient survived five years and finally died of recurrent disease. The Schauta-Amreich procedure was used in six patients. In our Clinic we believe there will be an increasing number of patients in whom this procedure is suitable, especially the elderly, poor-risk patient who has a small recurrence at the vaginal vault or on the cervix and should not have an extensive abdominal operation. The patient with this type of recurrent disease usually does not have positive glands. The postoperative complications are less than with abdominal procedures.’ The Schauta-Amreich procedure can be carried out in one hour with very little blood loss and can be very effective in patients who otherwise might be denied surgical treatment. Exenteration for recurrent disease was carried out in 37 of our patients (anterior exenteration in 18, posterior exenteration in nine, and total exenteration in 10). The fact that only 37 patients had exenterative procedures could be criticized, and we admit that there were a few more patients who possibly should have had a pelvic exenteration but for a number of reasons (patient refusal, poor operative risk, etc.) the exenterative procedure was not carried out.

Table III. Complications recurrence of carcinoma

of surgical management of of the cervix in 169 patients SO.

Complication Urinary fist&i Bowel

15

hstula

Thrombophlebitis Pulmonary embolus Ventral hernia Paralytic ileus Infection Cardiac arrest Halothane (liver damage) Renal failure Bowel obstruction Other Total complications Total patients with complications

Table IV. Comparison after primary surgical for recurrence

743

3 3 1 2 2 2 I I 1 1 II ii (?5.4%) 27 (16%)

of cumulative sur\ ival rates treatment and operation

1

92

50

2 3 4 5

90 88 88 88

38 38 37 35

Complications of surgical management of recurrence (Table III). There were a total of 43 complications in 27 patients (16 per cent). Included are 169 patients treated for recurrent disease, radioresistant tumor, palliative hysterectomy, negative or noninvasive disease, and radiation necrosis. It is interesting to note that most of the complications occurred in those patients who did not survive free of disease. This may be related to the poor immunologic response to infection in these cases. The complication rate in the patients who survived free of disease is less than half the above figure. Six urinary fistulas persisted until the patient died, four fistulas were repaired. and two fistulas closed spontaneously. Two patients had an ilial loop, and one patient had a failed repair of a fistula and died of disease a few months later. The mortality rate was nine of one hundred and sixty-nine patients. or 5.3 per cent. The mortality rate for the last 100 cases was 3 per cent. There were 12 patients with positive lymph nodes in 116 patients with Stage 1 disease treated by radical hysterectomy and node dissection, that is, 10.3 per cent, which is slightly lower than other published figures.’

744

Allen and Collins Am

April 1. 1977 J. Obstet. (hwc~,l.

There were 18 patients with Stage II carcinoma of the cervix treated in this manner, and eight of these, or approximately 45 per cent, had positive lymph nodes. This is rather high but the numbers are too small to be significant. There were three patients with Stage IV disease treated by primary exenteration, and one had positive lymph nodes. All are alive and well after over two years. Deckers and associate? have shown improved survival rates with this management of Stage IV disease. There were 12 of 63 patients with positive lymph nodes who had central recurrent disease treated by Wertheim hysterectomy and node dissection. Two are alive and well after over five years; three are alive and well at two to five years, and two patients are alive and well. free of disease, at under two years. Of the five patients who died, all died in less than two years. In the major part of this series we have not considered postoperative radiation for the patient who has positive nodes at the time of operation. In the last two years, we have given postoperative radiation to these patients. In our Clinic we believe that most patients with positive nodes should receive postoperative radiotherapy. Combined treatment has been shown by Rampone and co-workers” to give a 62.9 per cent fiveyear survival rate in patients with positive nodes in Stage IB carcinoma of the cervix. Stallworthy also has

reported improved survival rates \\ ith combined treatment. The days in the hospital for the patients with prlmary surgical treatment ranged from seven to 30 with an average stay of 14.5 days. For patients with recurrent disease, the time in the hospital ranged from six IO 78 days with an average stay of 21.8 days. Survival rates after primary surgical treatment for Stage I disease and after operation for recurrent disease are shown in Table IV. After two years, the survival rate is nearly the same up to five years in the patients with primary surgical treatment and those treated with operation for rcLurrent disease. The five-year survival rates for patients treated with radiation for the years 1969 and 1970 in our Clinic were 83.3 per cent f’or those with Stage 1 disease and 70 per cent for those with Stage II disease. The surgical experience in the management of carcinoma of the cervix in our Centre has been outlined. There are many hazards in this type of surgical treatment, especially following radiation. All the skill, ingenuity, and experience of the operating team are tested in reducing infection and preser\ing blood supply and healing potential without drcreasing the wide dissection necessary to give the best chance of removing all the malignancy. Operation dots add an important contribution to the management of this disease.

REFERENCES 1. Allen, H. H.: Surgical management of recurrent carcinoma of the cervix, Can. J. S&g. 4: 277, 1961. 2. Deckers. P. 1.. Ketcham. A. S.. Sueerbaker. E. V.. Hove. R. C., and’Th&as, L. B:: Peliic ekenteration for primary carcinoma of the uterine cervix, Obstet. Gynecol. 37: 647, 1971. 3. Love, E. J., and Allen, H. H.: Management of recurrent carcinoma of the cervix, AM. J. OBSTET. GYNECOL. 77: 539, 1959. 4. Mostafa, A., Kurchara, S. S., and Webster, J. H.: Surgical

or radiation therapy for cancer of the cervix stage I. Obstet. Gynecol. 38: 251, 1971. 5. Navratil, E.: Indications and results of the SchautaAmreich operation with and without postoperative roentgen treatment in epidermoid carcinoma of the cervix of the uterus, AM. J. OBSTET. GYNECOL. 86: 141. 1963. 6. Rampone, J. F., Valborg, K.. and Kolstad, P.: Obstet. Gynecol. 41: 163, 1973. 7. Stallworthy. J.: Ann. R. Coil. Surg. Engl. 34: 161, 1964.