In the name of God Isfahan medical school

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 ►early central pelvic recurrence Vaginal discharge and bleeding

► 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

Patients treated for cancer n n n n 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

• 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

Pelvic recurrence n n n 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

Treatment n n 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

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%

Preoperative Evaluation l l l l l 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

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

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

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

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

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

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

Prognosis • After anterior Exenteration 30 -60% five year survival • After total Exenteration 20 -4 -% • Mortality increase if 1 - size of recurrence > 3 cm 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%