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Cervical cancer
affects 3500 women per year in England and Wales, 75% of whom present
at an early stage in the disease. Recent audit shows that 20% (700)
are detected with pre-invasive disease using loop cone biopsy. The
mortality rate is less than 1000 per year.
The role of
surgery in cervical carcinoma is:
" As a
diagnostic procedure to obtain tissue
" As a curative procedure
" To indicate the need for adjuvant therapy
Surgical options,
in increasing complexity, are:
" Loop
excision
" Total abdominal hysterectomy
" Wertheims hysterectomy
" Trachelectomy/pelvic lymphadenectomy
Assessing the
stage of the carcinoma is a clinical judgement, and MRI is commonly
used today. Other procedures, which may be employed, are:
" Cystoscopy
" Sigmoidoscopy
" IVU
" CXR
Surgery is appropriate when all disease can be excised and it alone
will effect a cure. The most common type of surgery is the Wertheims
hysterectomy, a 3-hour procedure (compared to 1 hour for a total
abdominal hysterectomy)
Combined chemotherapy
and radiotherapy is a fairly new concept and although not suitable
for all patients has been shown in several clinical trials to be
an effective alternative to surgery. Survival rates are better than
chemotherapy or radiotherapy alone.
Using cisplation gives the best results with least side effects.
Patient support groups have been shown to be helpful.
A disadvantage
with combined chemo/radiotherapy is that options are limited in
the event of recurrence.
There is a 5%
chance of recurrence following trachelectomy, so it should only
be performed after counselling and where there is a strong wish
to preserve fertility. There is a 25% chance of miscarriage, a 30%
chance of premature labour and all cases to date have been delivered
by caesarean section.
Professor Kehoe
concluded that surgery in cervical cancer should be used with the
intention of cure. Fertility can be preserved but follow up is limited
and patient selection is paramount. Chemo/radiotherapy has replaced
surgery in some cases.
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