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In the name of God

In the name of God. Isfahan medical school Shahnaz Aram MD. Recurrent cervical cancer. Within 6 months after completion of primary therapy = persistent After 6 months = recurrent 1/3 patients experience tumor recurrence Symptoms depend on the site and extent of tumor

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In the name of God

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  1. In the name of God Isfahan medical school Shahnaz Aram MD

  2. Recurrent cervical cancer Within 6 months after completion of primary therapy = persistent After 6 months = recurrent 1/3 patients experience tumor recurrence Symptoms depend on the site and extent of tumor early central pelvic recurrence Vaginal discharge and bleeding

  3. Widespread metastasis  malaise, loss of appetite, general symptoms • Lateral pelvis recurrence has late manifestations • Unilateral leg edema is due to lymphatic fibrosis after operation or radiation • Urethral obstruction, unilateral or bilateral  decrease in kidney function , low back pain

  4. 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

  5. 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

  6. 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

  7. Treatment • Depends on 1- mode of primary therapy 2- site of recurrence • If in pelvis after radiation , most patients Exenteration • TAH is inadequate • Occasional patients may be salvaged by radical hysterectomy

  8. 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%

  9. 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

  10. Exploratory laparatomy • Parametrial Biopsy ( fibrosis) • Bowel preparation • Parenteral nutrition • Prophylaxy for DVT • Surgical mortality increases with age • > 70? • Surgical mortality < 10% • Mortality due to hemorrhage, pulmonary thromboembolism, sepsis • Fistula 30-40% mortality

  11. Pelvic Exenteration • Contraindicated surgery if 1- unilateral leg edema 2- sciatic pain 3- urethral obstruction • Exenteration if central pelvic recurrence • 25% of patients are candidate for Exenteration • Exenteration is not performed for palliative • Before Exenteration metastasis must be ruled out by lymph node biopsy, frozen section, operative margin

  12. Exenteration 1- anterior 2- posterior 3- total • After total Exenteration  new pelvic floor • Left gastrioepiploic art release and omentom replacement • Supra levator Exentraation (if 1/3 upper is involved and frozen section of the lower pelvis is negative ) • 5 year survival after Exenteration is 45-61%

  13. Non-pelvic recurrence • Recurrence outside of the pelvis • Treated with radiation, operation, chemotherapy • Local recurrence with radiation • Resection of the metastasis is rarely done unless (local, 3-4 years after primary therapy) • General distant metastasis , no cure with local excision

  14. Radiation re-treatment • In suboptimal incomplete primary therapy • Curative dose ( risk for bladder, rectum) • Insertion multiple interstitial radiation source in local recurrence • For curable patient, Exenteration is better • Radiotherapy 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

  15. Chemotherapy • Palliative • For extra-pelvic metastasis • Relief of symptoms • Prolongation of life • Complete response is unusual • Chemotherapy for small cell carcinoma of cervix • Unresectable pelvic recurrence • General limited for lung metastasis • For a distant metastasis • Cisplatin = most clinical response • Duration of response is 4-6 months • 2 cases more than 5 years • Chemoradiation 1- sensitized of cervical cancer cells 2- eliminate microscopic systemic metastasis • GOG cisplatin or cisplatin + paclitaxel

  16. Prognosis • After anterior Exenteration  30-60% five year survival • After total Exenteration  20-4-% • Mortality increase if 1- size of recurrence > 3cm 2- bladder invasion 3- positive pelvic lymph node 4-Recurrence after one year after radiation 5-Peritoneal disease Five year survival if positive lymph node = 5%

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