Surgery

for Cervical Cancer

Surgery is a local therapy to remove precancerous tissue or cancer in or near the cervix. A surgeon who specializes in treatment of disorders of the female reproductive tract is known as a gynecologist. Some gynecologists have special training in treatment of cancers of the female reproductive tract, and are known as gynecologic oncologists. Gynecologic oncologists have developed expertise in performing surgical treatment of cancer of the cervix.

Cervical Biopsy

If a pelvic examination or Pap smear result suggests that cervical cancer may be present, the patient will need to have a biopsy. A biopsy is the only way to know for sure whether a patient has cancer. During a biopsy, an instrument is used to remove small pieces of cervical tissue. The pieces of cervical tissue are then examined under the microscope to determine whether cancer cells are present. A cervical biopsy can be performed in the office using a special microscope called a colposcope, or occasionally in the operating room during a more thorough examination while the patient is asleep.

Conservative Surgery for Precancerous Cervical Disease

Surgery is a standard treatment of precancerous cervical disease. The type of operation used to remove the precancerous disease depends on how abnormal the cells appear to be under the microscope, the patient’s general medical condition and whether the patient wishes to have children in the future. A number of surgical procedures are effective in treating precancerous cervical disease. Most procedures do not involve removal of the uterus and can permit future childbearing if desired by the patient.

Surgical procedures that preserve the uterus and may permit future childbearing include cryosurgery (freezing), laser surgery, loop electrosurgical excision procedure (LEEP) or cold-knife conization. Cryosurgery, laser surgery and LEEP can be performed in the doctor’s office or outpatient short procedure center, often with local anesthesia. A cold-knife conization is a more extensive operation that involves removal of part of the cervix under general anesthesia. Not all patients can be adequately treated with cryosurgery, laser surgery or LEEP. This decision depends on the extent and appearance of the disease on examination.

Women who undergo one of these surgical procedures may experience cramping or pain in the pelvis, infection, bleeding or watery discharge. Watery discharge can persist for several weeks following cryosurgery. Women who undergo a cold-knife conization may have difficulty with cervical function during a future pregnancy.

Even with surgical treatment of precancerous cervical disease, some patients may experience recurrence of precancerous disease or invasive cancer. Treatment of stage 0 cervical cancer with cryosurgery, laser surgery or LEEP cures 85-90% of women. Approximately 10-15% may experience a recurrence of precancerous cervical disease and approximately 2% will develop invasive cancer following treatment with these procedures. Women treated with conservative surgery require lifelong visits to their doctor to ensure that recurrence of cervical disease can be detected in the precancerous state or early while the cancer is still curable.

Robotically-assisted Hysterectomy Appears Effective for Cervical Cancer

Robotically-assisted hysterectomy (RAH) in patients with early-stage cervical cancer is at least as effective as traditional open radical hysterectomy (ORH) and produces fewer complications, according to the results of a study published in the October 2008 issue of the American Journal of Obstetrics and Gynecology.1

Cervical cancer affects the cervix, the part of the body that connects the uterus (or womb) to the vagina (or birth canal). Treatment of cervical cancer depends on the stage (or extent) of disease at diagnosis and may include surgery, radiation, chemotherapy or other innovative strategies. Women who receive treatment for early-stage cervical cancer generally have an excellent prognosis, with a cure rate of greater than 90%.

One common treatment strategy for cervical cancer is a radical hysterectomy, which involves the surgical removal of the cancer, uterus, cervix, and part of the vagina through a low abdominal incision. A radical hysterectomy allows for the removal of the cancer and also reduces the risk of recurrence.

Each year, more than 600,000 hysterectomies are performed for treatment of cancer, uncontrollable bleeding, fibroids, polyps, or chronic pain, making it the second most common surgery among women of reproductive age in the United States. One in three women has had a hysterectomy by age 60. Women undergoing a radical hysterectomy may experience lower abdominal pain at the site of incision, bleeding, or infection after the operation. In addition, some women may experience difficulty with urination or problems with bladder control.

Robotically-assisted radical hysterectomy (RAH) is a new technique during which a surgeon sits at a remote console viewing a magnified 3D image of the surgical site. From here, the surgeon can manipulate four tiny robotic arms inside the patient. These arms mimic the intricate movements of a surgeon’s hands and wrists in real time, which allows for complex and precise techniques. Furthermore, through special hardware and software components, the system even filters out natural hand tremors, which adds to its accuracy. Finally, the robotic arms make dime-sized incisions, whereas a major incision is required with traditional hysterectomy.

In a recent study, researchers at the University of North Carolina compared the outcomes of 51 patients who underwent RAH with those of 49 patients who underwent traditional open radical hysterectomy (ORH). They found that patients who underwent RAH experienced less blood loss and shorter hospital stays than patients who underwent ORH. All RAH patients were discharged the day following surgery compared with an average hospitalization of approximately three days for the ORH group. Furthermore, the incidence of postoperative complications was almost 8% for the RAH group compared with approximately 16% for the ORH group.

Boggess JF, Gehrig PA, Cantrell L, et al. A case-control study of robot-assisted type III radical hysterectomy with pelvic lymph node dissection compared with open radical hysterectomy. American Journal of Obstetrics and Gynecology. 2008; 199: 357.e1-357.e7.

Simple Hysterectomy

A hysterectomy is a common treatment of stage I cancer and precancerous disease of the cervix. The type of hysterectomy used to remove the cervical cancer depends upon the extent of the cancer.

If the precancerous disease is more extensive and the patient desires no further children, a simple hysterectomy can be performed. During a simple hysterectomy, the entire uterus, including the cervix with the precancerous disease and an area of normal tissue around it, is removed through a low abdominal incision or the vagina. A simple hysterectomy is very effective therapy if the cancer has not invaded beyond the surface cell layer of the cervix. In addition, doctors can perform a bilateral salpingo-oophorectomy, which is the removal of the ovaries and fallopian tubes. The decision to perform a bilateral salpingo-oophorectomy depends on the woman’s age and whether the ovaries are still functioning.

A simple hysterectomy and/or a bilateral salpingo-oophorectomy are the most extensive surgical options used for precancerous disease and require general anesthesia and a hospital stay. Women undergoing a hysterectomy may experience lower abdominal pain and difficulty with urination after the operation. After a hysterectomy, women no longer menstruate and can no longer have children.

Radical Hysterectomy

A radical hysterectomy is more extensive surgery that involves the removal of the entire uterus, including the cervix, with the cancer and an area of normal tissue through a low abdominal incision. This area of normal tissue also includes a portion of the upper vagina and may result in vaginal shortening after the operation, but rarely causes sexual problems. As with a simple hysterectomy, doctors might opt to perform a bilateral salpingo-oophorectomy, which is the removal of the ovaries and fallopian tubes. The decision to perform a bilateral salpingo-oophorectomy depends on the woman’s age and whether the ovaries are still functioning.

Women undergoing a radical hysterectomy may experience lower abdominal incisional pain, bleeding or infection after the operation. In addition, some women may experience difficulty with urination or problems with bladder control. Less commonly, some women may have injury to the rectum, ureters (tubes that drain the kidneys) or bladder. One type of injury may be in the form of a “fistula” or abnormal connection to the vagina. After a hysterectomy, women no longer menstruate and can no longer have children. With radical hysterectomy and pelvic lymph node dissection alone or, more commonly, when it is combined with radiation therapy, women are at higher risk for bowel complications and chronic swelling in the legs, known as lymphedema. In-hospital death occurs after radical hysterectomy in less than 1% of cases.

Hysterectomy and Pelvic Lymph Node Dissection

A radical hysterectomy is most effective if the exploration during surgery shows that the cancer has not spread beyond the cervix. Some patients will have cancer that has spread outside the cervix into the lymph nodes in the pelvis. Before performing a hysterectomy, the doctor will sometimes perform a pelvic lymph node dissection, which is surgery to remove lymph nodes to see if they contain cancer. If the lymph nodes contain cancer, usually the surgeon will not proceed with a radical hysterectomy. Another form of treatment, usually radiation therapy and chemotherapy, is generally recommended.

Even after surgical removal of cervical cancer, some patients may experience recurrence of their cancer. Cancer recurrence occurs more commonly with bulky stage IB or stage II cervical cancer. It is important to realize that some patients with cervical cancer already have small amounts of cancer that have spread outside the cervix and were not removed by surgery. These cancer cells cannot be detected with any of the currently available tests. Undetectable areas of cancer outside the cervix are referred to as micrometastases. The presence of these micrometastases causes recurrence following the initial treatment. External beam radiation therapy with or without implant radiation and chemotherapy are often recommended to cleanse the body of micrometastases in order to improve the cure rate achieved with surgical removal of the cancer.

Retroperitoneal Lymph Node Dissection and Scalene Lymph Node Biopsy

Patients who cannot undergo surgery to remove the cancer or who have advanced stage cervical cancers will often receive radiation therapy usually combined with chemotherapy. Before radiation therapy is delivered, it is helpful to know if the lymph nodes in the abdomen and pelvis have small deposits of cancer in them. This is determined by an operation called a retroperitoneal lymph node dissection. During this operation, a small incision is made in the middle abdomen and the surgeon removes the lymph nodes, which lie behind the abdominal contents. Most patients are able to leave the hospital after a day or two and begin treatment with radiation therapy shortly afterwards. If the sampled lymph nodes contain cancer, the radiation oncologist may modify treatment to include these areas of microscopic disease.

Some patients have advanced cervical cancer when they are diagnosed. In these patients, it is important to know whether disease has spread outside the pelvis to distant parts of the body. One method is to perform a small operation to dissect the lymph nodes at the base of the left neck. This operation is called a scalene lymph node biopsy, and can be performed on an outpatient basis. Subsequent treatment may depend on the results of this biopsy.

Strategies to Improve Treatment

The progress that has been made in the treatment of cervical cancer has resulted from improved development of treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of cervical cancer will result from continued participation in appropriate clinical trials. Currently there are several areas of active exploration aimed at improving the treatment of cervical cancer.

Preservation of Reproductive Function: Generally, women who receive treatment for stage I cervical cancer have an excellent prognosis, with a cure rate of greater than 90% following a hysterectomy. However, some women of childbearing age would prefer a therapy that preserves their reproductive function. One such procedure for preserving reproduction function is a radical trachelectomy, which only removes a portion of the uterus. In a recent clinical study, 32 patients with stage I cervical cancer measuring 2cm or less who were treated with radical trachelectomy experienced a 2-year survival rate of 95%, without any relapse of the cancer. Approximately 40% of women were able to conceive after treatment.

Ovarian Transplantation Into Forearm: A new procedure that involves the permanent placement of a section (cortical strip) from a patient’s ovaries into her forearm may preserve fertility and normal ovarian function in pre-menopausal women who are treated with radiation to the pelvic area or undergo the removal of their ovaries.

Researchers evaluated the surgical procedure in two women, a 35-year-old with advanced cervical cancer who was to undergo pelvic radiation and a 37-year-old with benign cysts on her ovaries who was to undergo an oophorectomy. Both patients had cortical strips removed from their ovaries and permanently transplanted to the forearm. The first patient received her transplant prior to radiation and the second patient received her transplant during the oophorectomy. Ten weeks following surgery, the transplant tissue in both patient forearms had resumed the production of ovarian hormones and the development of follicles (eggs). One patient has actually ovulated and the other patient is producing cyclical hormone levels indicative of ovulation. Besides normal hormonal function, the other end goal of this procedure is to be able to harvest eggs from the transplanted ovarian strips so that pre-menopausal patients having to undergo treatment that normally causes sterility can bear children.

Next: Radiation Therapy for Cervical Cancer

References

1 https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site