SERVİKS KANSERİNDE İNKOMPLET CERRAHİYE YAKLAŞIM Dr. Hakan Ozan
Sistematik Parametrektomi +/- RT ? Surgery No. of patients 13 Approach, n patients (%) Robotic-assisted laparoscopy 3 (23.1 %) Laparoscopy 7 (53.8 %) Vaginal and laparoscopy Operative time (minutes) 302 (range 220–400) Length of stay (days) 4 (range 3–10) Operative complications Postoperative complications 1 lymphedema 1 pelvic lymphocyst (CT drainage) Adjuvant therapy, n (%) Only surgery: 8 (61.6 %) Pelvic radiation therapy 1 (7.7 %) Brachytherapy Pelvic radiation and brachytherapy Narducci F, et al. Occult invasive cervical cancer found after inadvertent simple hysterectomy: is the ideal management: systematic parametrectomy with or without radiotherapy or radiotherapy only? Ann Surg Oncol 2015; 22: 1349-52
Radiation therapy Number of patients 16 Type of treatment Pelvic radiation therapy 2 (12.5 %) Brachytherapy 5 (31.3 %) Pelvic radiation and brachytherapy Concomitant chemoradiation Concomitant chemoradiation and brachytherapy
Peritoneal sitoloji+1/3 üst vajinektomi+Radikal parametrektomi+BPPLND 25 olguda cerrahi Peritoneal sitoloji+1/3 üst vajinektomi+Radikal parametrektomi+BPPLND rezidüel mikroskobik hastalık 10 (%37.03)olguda Lenf nodu tutulumu 6 (%22.2) olguda Tümör serviks ile sınırlıysa 3 (%11.1) Ayhan A, et al. Radical reoperation for invasive cervical cancer found in simple hysterectomy J Surg Oncol 2016; 94: 28-34
Rezidüal hastalıkta metastaz lokasyonları? Ayhan A, et al. Radical reoperation for invasive cervical cancer found in simple hysterectomy J Surg Oncol 2016; 94: 28-34
Neden Radikal parametrektomi? Toplam sağkalım (%) p Pelvik lenf nodu tutulumu 0.01 (+) %66.67 (-) %100 Para-aortik lenf nodu tutulumu 0.66 %91.30 Vajinal apeks tutulumu <0.01 %60 Lu HW, et al. Can radical parametrectomy be omitted in occult cervical cancer after extrafascial hysterectomy Chin J Cancer 2015; 34: 413-9
Kimlere adjuvan tedavi? Parametre Postop adjuvan (-) (n=16) Postop adjuvan (+) (n=11) p LVSI <0.01 (+) 5 (%35.7) 9 (%64.3) (-) 11 (%84.6) 2 (%15.4) Grade - 1 8 (%100) 2 2 (%33.3) 4(%66.7) 3a 2 (%100) (a)İstatistiki anlamlılığı oluşturan ana faktör
Vajinal apeks metastazı Pelvik lenf nodu metastazı Median takip 33 (14-136) ay, toplam sağkalım %88.89, Hastalıksız sağkalım %88.67 Toplam sağkalım; Anaplastik karsinom Vajinal apeks metastazı Pelvik lenf nodu metastazı varlığında anlamlı olarak azalır.
Hangi hastalar radyoterapiden korunabilir? Çalışma n Evre Tümör Boyutu İnvazyon derinliği LVSI Lenf nodu tutulumu Yaş Parametriyum tutulumu (%) Gemer 530 IA2–IB1 ≤2 cm N − Kodama 200 IB1 <10 mm <50 Frumovitz 125 Stegema 103 <2 cm 0.63 Wright 594 IA–IIA 0.4 Covens 842 IA–IB1 ≤10 mm 0.6 Kinney 387
Parametriyal tutulum için değişkenler nelerdir? Lu HW, et al. Can radical parametrectomy be omitted in occult cervical cancer after extrafascial hysterectomy Chin J Cancer 2015; 34: 413-9 Variables (200 Evre IBI) Parametrial involvement P value Negative (N = 180) Positive (N = 20) Depth of invasion (mm) 8.5 (2–25)a 14.0 (5–23.5) < 0.0001 Tumor size (mm) 19 (7–38)a 23 (10–34) 0.001 LVSI Negative 108 (97%) 3 (3%) Positive 72 (81%) 17 (19%) Pelvic LN metastasis 163 (95%) 8 (5%) 17 (59%) 12 (41%) Ovarian metastasis 180 (91%) 18 (9%) 0 (0%) 2 (100%) Age(years) 41.5 (25–71)a 55.0 (26–66) 0.007 (a)(Median (Range)
Parametrial involvement Variable Parametrial involvement Nodes positive DOI/LVSI 10 mm or less, LVSI (−) (N = 91) 1 (1.1%) 3 (3.3%) 10 mm or less, LVSI (+) (N = 34) 3 (8.8%) 6 (17.6%) More than 10 mm, LVSI (−) (N = 20) 2 (10.0%) 1 (5.0%) More than 10 mm, LVSI (+) (N = 55) 14 (25.4%) 18 (32.7%) Tumor size/LVSI 2 cm or less, LVSI (−) (n = 87) 2 (2.3%) 2 cm or less, LVSI (+) (n = 32) 4 (12.5%) 6 (18.8%) More than 2 cm, LVSI (−) (n = 24) 2 (8.3%) More than 2 cm, LVSI (+) (n = 57) 13(22.8%) 18 (31.6%) DOI: Depth of invasion
Variable Parametrial involvement Nodes positive DOI ≤ 10 mm, LVSI (−), age ≤ 50 (n = 68) 0 (0.0%) 2 (2.9%) DOI ≤ 10 mm, LVSI (−), age > 50(n = 23) 1 (4.3%) TS ≤ 2 cm, LVSI (−), age ≤ 50 (n = 64) 1 (1.6%) TS ≤ 2 cm, LVSI (−), age > 50 (n = 23) DOI: Depth of invasion
Kinney 1B1 SCC < 2 cm Neg. Class II RH (5%) 0/83 4/83 Covens Kodama J, et al. Factors associated with parametrial involvementin stage IB1 cervical cancer and identificationof patients suitable for less radical surgery Gynecol Oncol 2011; 122: 491-4 Author Stage Histology Tumor size Depth of invasion Lymph node LVSI Others Risk of parametrial spred Risk of lymph metastasis Kinney 1B1 SCC < 2 cm Neg. Class II RH (5%) 0/83 4/83 Covens 1A1–1B1 All < 10 mm 1A (39%) Class II RH (100%) 3/536 Wright 1A1–2A 1A (8%) Class II RH (2%) 1/270 Stegeman 1A (4%) < 45 years old 0/67 Frumovitz 1A2–1B1 ≤ 2 cm 1A (12%) 0/125 1/125 Kodama 1/87 2/87 Total 5/1168 (0.4%) 6/295 (2.0%)
Takip süresi(ay), median (aralık) 116 (3–235) 104 (7–232) 100 (9–232) Parametre (%) Toplam Takip veya KT RT veya KTRT RP p n 147 (%100) 26 (%17.7) 44 (%29.9) 29 (%19.9) Takip süresi(ay), median (aralık) 116 (3–235) 104 (7–232) 100 (9–232) 73 (3–220) 0.068 Rekürrens, n (%) 12 (8.2) 9 (34.6) 3 (6.8) 0 (0.0) 0.272 Ölüm, n (%) 6 (4.1) 4 (15.4) 2 (4.5) 0.514 10-yıl DFS (%) 91 63 93 100 0.199 10-yıl OS (%) 96 84 94 0.276 Park JY, et al. Management of occult invasive cervical cancer found after simple hysterectomy Ann Oncol 2010; 21: 994-1000
Tedavi etkinliği? Park JY, et al. Management of occult invasive cervical cancer found after simple hysterectomy Ann Oncol 2010; 21: 994-1000