A lady undergoes total radical hysterectomy for stage Ib Ca cervix. It was found that Ca extends to lower pail of body of uterus and upper pa of cervix. Next step of management will be
Follow up This patient has stage Ib Ca cervix (i.e. clinical lesion confined to cervix). Management of Ca cervix consists of Primary management and Post-op management. Primary Mx of Ib Radical hysterectomy + lymphadenectomy (detailed Mx of Ib described ahead) Post surgical management depends on presence or absence of risk factors. So here this patient has stage Ib Ca cervix - She has undergone total radical hysterectomy, which is the appropriate primary management. Post-op it is found that carcinoma is extending to lower pa of body of uterus. This is the tricky pa of the question. - an extension to uterus is given no consideration in FIGO clinical staging of Ca Cervix. Fuhermore Novak writes - "After a clinical stage is assigned and treatment has been initiated the stage must not be changed because of subsequent findings of either extended clinical staging or surgical staging". So a finding of uterus involvement is not going to change the stage or the management. Post op. management (i.e. either follow up, radiotherapy or chemoradiation) is going to be determined by presence or absence of risk factors. In the question, no risk factor has been mentioned (uterine involvement is not a risk factor). So we assume that none are present and hence fuher management would be -> 'follow up' Management of Ca Cervix Primary Management of Note - Radiotherapy can also be used for stages la to Ila if patient is medically inooperable. Trachelectomy or cervicectomy refers to surgical removal of cervix. In radical trachelectomy parametria and vaginal cuff are also excised along with removal of cervix. This is a feility preserving alternative to radical hysterectomy in younger patients with early stage carcinoma. Types of hysterectomy Type I - Simple (extrafascial) hysterectomy routinely done for benign conditions for e.g. fibroid. Type II - (Weheim's or modified radical hysterectomy) In type II along with hysterectomy, medial half of the cardinal and uterosacral ligaments and proximal 1-2 cm of vagina are also removed. Type III - (Meigs radical hysterectomy) It includes removal of most of the uterosacral and cardinal ligaments and the upper one third of the vagina. Both type II & type III hysterectomy includes pelvic lymph node dissection. Type IV - (extended radical hysterectomy) In type IV, the periureteral tissue, superior vesical aery, and as much as 3/4th of vagina in addition are removed. Type V (paial exenteration) - Poions of the distal ureter and bladder are resected. Type IV & V are rarely performed because radiotherapy is more adequate treatment in extensive disease. These factors are seen during histopathological examination of specimens (uterus, cervix, parametria, vaginal cuff, lymph nodes etc.) of radical hysterectomy and lymphadenectomy. Let's also have a revision of Ca Cx staging FIGO Staging of Carcinoma of the Cervix Preinvasive Carcinoma 0 Carcinoma in situ Invasive Carcinoma I Carcinoma is strictly confined to the cervix lA Invasive cancer identified only microscopically. All gross lesions even with superficial invasion are stage lB cancers. Invasion is limited to measured stromal invasion = 5 mm deep and < 7 mm wide. IA1 Measured invasion of stroma <3 mm deep and <7 mm wide IA2 Measured invasion of stroma >3-5 mm deep and <7 mm wide IB Clinical lesions confined to the cervix or microscopic lesions greater than stage IA M1 Clinical lesions <4 cm in size 1B2 Clinical >4 cm in size II Carcinoma extends beyond the cervix but has not extended to the pelvic wall or lower third of the vagina. IIA No obvious parametrial involvement IIB Obvious parametrial involvement III Carcinoma has extended to the pelvic wall. On rectal examination, there is no cancer free space between the tumor and the pelvic wall. The tumor involves the lower third of the vagina. All cases of hydronephrosis or nonfunctioning kidney are included unless known to be due to another cause. IIIA No extension to the pelvic wall IIII3 Extension to the pelvic wall, hydronephrosis, or nonfunctioning kidney IV Carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. Bullous edema does permit a case to be allocated to stage IV. IVA Spread of growth to adjacent organs IVB Spread to distant organs
Chemotherapy
Radiotherapy
Chemoradiation
Follow-up