Surgical techniques for treatment of cervical cancer

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Cervical cancer is the second most common among women. Infection with the Human Papilloma Virus (HPV) remains the biggest risk factor for developing cervical cancer.  Although vaccines are now available for some of the types of HPV, it still is not available widely. There are various treatment options for cervical cancer such as radiotherapy, chemotherapy and surgery. Here we will discuss various surgical techniques according to the location and type of cervical cancer.

Surgical treatments for cervical cancer

A surgical oncologist will decide the type of surgery to be performed at a specific stage. This decision depends on the type of cancer, its size and hence its stage.

Surgery Types:

For cancers limited to the surface of the cervix, a cone biopsy is sufficient to treat cancer. In some cases of early stage, cervical cancer a radical trachelectomy is performed, which allows the patient to have still children after treatment as the uterus is still left in place. This type of surgery is called fertility-preserving surgery.

In cases where cancer has not yet spread beyond the pelvic cavity, the following treatment options are available.

Conization

This is a procedure used for treatment of cervical cancer in which a piece of tissue from the cervix in the shape of a cone is removed by either a surgical procedure or laser knife or by a wire that is heated by electricity also called a loop electrosurgical procedure. A cone biopsy may be used to diagnose cancer before additional treatment with surgery or radiation may be required. It can also be used as the only treatment in women with early (stage IA1) cancer who want to preserve their ability to have children (fertility). After the biopsy, the tissue removed (the cone) is examined under the microscope. If the margins (outer edges) of the cone contain cancer (or pre-cancer) cells, further treatment will be needed to make sure that all of cancer has been removed.

LEEP

An electric wire with a hoop is guided into the cervix through the vagina, and a tissue sample is collected on the hoop (via diathermy). The tissue is sent for further evaluation to the laboratory. This may be used to treat micro-invasive cancers also.

Hysterectomy

Laparoscopic or an abdominal hysterectomy may be performed for the treatment of cervical cancer.

– Simple Hysterectomy

This involves the removal of the cervix and the uterus leaving the lymph nodes in place.

– Radical Hysterectomy

Radical Hysterectomy is a rather extensive procedure that involves removal of the uterus, the cervix, parts of the surrounding cervical tissue (called parametric), the upper part of the vagina, the fallopian tubes with or without the ovaries and removal of all pelvic lymph nodes.

Bilateral Salpingo-Oophorectomy

This involves removing both the ovaries and the fallopian tubes. It is usually performed at the time of removal of the uterus.

Total Hysterectomy

This may be further divided into vaginal, abdominal or laparoscopic, depending upon the site from which the cervix and uterus are removed.

– Vaginal hysterectomy:

Involves removing the uterus through the vagina.

– Abdominal hysterectomy:

Involves removal of the uterus through a large incision in the abdomen.

– Laparoscopic hysterectomy:

Involves a key-hole surgery in which multiple small incisions are made in the abdomen and the uterus and cervix removed after visualizing them with a camera inserted into the abdomen through the earlier made incisions.

Modified Radical Hysterectomy:

Modified radical hysterectomy removes lesser structures than a radical hysterectomy. In MRH the cervix, uterus, upper part of the vagina, lymph nodes and some surrounding ligaments are removed.

Radical Trachelectomy

For patients wishing to preserve their fertility, a radical trachelectomy is performed. This procedure involves removal of the cervix without removing the uterus. This surgery is used as an alternative to hysterectomy for young patients or those wishing to preserve their fertility.

Pelvic Exenteration

It is a surgical procedure used for the treatment of cervical cancer by removing various organs from the pelvis. The organs removed in the procedure include the vagina, cervix, large intestine, bladder, uterus and the adnexa. Since it’s a major surgical procedure everyone is not a candidate to receive it. This is to be decided by testing using computed tomography or magnetic resonance imaging before surgery.

The different types of exenteration procedures are:

  • Posterior (back) Exenteration.
  • Total Exenteration
  • Anterior (front) Exenteration.

Cryosurgery

Cryosurgery or Cryotherapy refers to the process of freezing the abnormal cells by placing a metal probe which is cooled liquid nitrogen is placed on to the abnormal cells. The patient is placed in the lithotomy position, and a speculum is inserted into the vagina to open the vagina. A cold probe is then inserted to freeze and hence destroy the abnormal cells. This treatment is only available for precancerous stage and cannot be used for the invasive stage.

Laser Surgery

This type of surgery is also used to treat precancerous stages and not invasive cancers. A focused laser beam is directed to the area containing the abnormal cells through the vagina and is used to vaporize the abnormal cells.

Pelvic Lymph Node Dissection

The carcinoma of the cervix can metastasize to the surrounding lymph nodes that are aggregations of immune tissues. Hence to rule out the involvement of nodes, the surgeon has to dissect or remove a lymph node, and the procedure is called node dissection.

Keyhole Surgery

Currently, surgeons prefer performing the “keyhole operation” for the removal of the uterus in the treatment of cervical carcinoma. This is synonymous with the terms laparoscopic operation or minimal access surgery. In these procedures, doctors use a small telescope-like instruments inserted in the body through smaller incision sites. The surgeon can visualize the internal organs through a camera that is also inserted through one of the incision sites. The recovery period is cut to about half in minimal access surgery when compared to open surgery. In certain cases if the spread of the cancer is extensive lymph nodes may also be removed. However in younger patients surgeons try to conserve the ovaries since their removal will lead to menopause, but in cases when their removal is required, the patient would be given therapy for the replacement of hormones that may be formed like creams

Conclusion:

Cervical cancer can be treated by various surgical methods depending upon the type and location of cervical cancer.Conization is used for patients who want to preserve their fertility.Hysterectomy can be abdominal, vaginal or laparoscopically, depending upon cancer metastasis. Other methods include pelvic exenteration, cryosurgery and pelvic lymph node dissection.

Reference:

Treatment of cervical cancer

 

 

 

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