Cancer du col utérin et coelioscopie Emile Daraï, Emmanuel Barranger, Roman Rouzier, Serge Uzan. Service de Gynécologie-Obstétrique Hôpital Tenon , CancerEst, Université Pierre et Marie Curie Paris 6, France First of all, I would like to thank the committee of organization for his invitation to speak on

Classification anatomique des cancers du col

Classification FIGO

Tumeur localisée du col stade Ib1

Tumeur du col stade Ib2 4 cm

Cancer du col stade Ib2

Atteinte vaginale stade IIa

Atteinte paramétriale stade IIb

Cancer du col stade III urinaire

Cancer du col stade IV: atteinte vésicale

Moyens thérapeutiques du cancer du col Chirurgie exclusive. Radiothérapie exclusive. Association radio-chirurgicale. Association radio-chimiothérapie concomitante. A part traitement conservateur: - trachélectomie élargie, - ganglion sentinelle.

Indication chirurgicale pour les cancers du col de stade Ib1 Pas de standard: Options: - Chirurgie première; Piver II ou III et lymphadénectomie - Irradiation exclusive: radio et curiethérapie - Association radio-chirurgicale: curiethérapie, ± radiothérapie externe Piver II ou III et lymphadénectomie

Indication chirurgicale CancerEst pour les cancers du col de stade Ib1 Désir de grossesse et lésion < 2 cm: trachélectomie élargie (problème des adénocarcinomes) Lésion > 2 cm ou lésion < 2 cm sans désir de grossesse: colpohystérectomie élargie coelioscopie ou Amreich-Schauta

Faisabilité de la colpo-hystérectomie élargie pour cancer du col Since the first laparoscopic radical hysterectomy performed by Canis in 1989, several series have confirmed its feasibility. As for abdominal radical hysterectomy, the main indications are women with Stage IA or IB1 cervical or IIa with small tumour size cancer. However, Hertel and Malur reported for locally advanced cervical cancer a laparoscopic treatment. Although some authors performed laparoscopic radical hysterectomy for locally advanced stages, several prospective trials have underlined the relevance of first concomitant radiochemotherapy.

Complications de la colpo-hystérectomie élargie pour cancer du col As in our experience, Spirtos and Pomel performed an exclusive laparoscopic radical hysterectomy whereas all others authors use a combined laparoscopic and vaginal technique. The mean operating time varied according to series between 205 and 380 minutes. The mean operating time was higher than 300 minutes for our first 20 cases but is now less than 200 minutes including the time for sentinel node procedure. Whatever the series, an acceptable intra-operative complication rate has been reported ranging from 2% to 13%.

Complications et survie après colpo-hystérectomie élargie pour cancer du col The rate of post-operative complications is mainly related to urinary disorders including infection and dysuria. To our knowledge, no death subsequent to laparoscopic radical hysterectomy has been reported.

Complications de la colpo-hystérectomie élargie: coelio vs laparotomie When comparing the morbidity of laparoscopic radical hysterectomy with those from the metaanalysis performed by Magrina including seven studies of abdominal radical hysterectomy, no difference in post-operative complications were found between the two routes. In our experience of 52 operations, 3 ureteral stenosis and 1 urinary fistula occurred but always in women with locally advanced stages carcer treated by first concomitant radiochemotherapy followed by Piver II operation. Hertel et al, Gynecol Oncol 2003

Survie globale de la colpo-hystérectomie élargie pour cancer du col On a large series including 200 women, Hertel reported an overall survival rate about 80%. Hertel et al, Gynecol Oncol 2003

Survie après colpo-hystérectomie élargie pour cancer du col de stade Ia ou Ib1 For women with stage Ia or Ib1 cervical cancer, the overall survival reached 97%. Hertel et al, Gynecol Oncol 2003

Survie sans récidive après colpo-hystérectomie élargie pour cancer du col en fonction de l’envahissement lympho-vasculaire In addition to tumour stage, Lymphovascular space involvement appeared a major prognostic factor of survival. Disease-free survival was 35%for women with both lymphatic and vascular involvement and 85% for women without lymphovascular involvement. Hertel et al, Gynecol Oncol 2003

Survie sans récidive après colpo-hystérectomie élargie en fonction du statut ganglionnaire After exclusion of women with no lymph node involvement, Hertel et al found a relation between the number of positive lymph nodes and survival. Hertel et al, Gynecol Oncol 2003

Colpo-hystérectomie élargie pour cancer du col: coelio vs laparotomie Recently, in a case control study, Nam demonstrated that abdominal and laparoscopic radical hysterectomy had similar operating time, number of lymph nodes removed, blood loss and transfusion rate but hospital stay was shorter for women treated by laparoscopy. Nam et al Gynecol Oncol 2004

Colpo-hystérectomie élargie pour cancer du col: coelio vs laparotomie Steed in a study comparing 71 women after laparoscopy and 205 women after laparotomy observed a higher operating time and intra-operative complication rate for laparoscopy but a lower blood loss. Steed et al, Gynecol Oncol 2004

Colpo-hystérectomie élargie pour cancer du col stade Ia-Ib: coelio vs laparotomie In contrast, no difference in post-operative complications was found. As in our experience, a higher rate of dysuria was noted after laparoscopic radical hysterectomy. No clear explanation has been suggested. Steed et al, Gynecol Oncol 2004

Survie après colpo-hystérectomie élargie pour cancer du col stade Ia-Ib: coelio vs laparotomie LARVH RAH For women with stage IA or IB, Steed found no difference in overall survival between women operated on by laparoscopy or laparotomy. Steed et al, Gynecol Oncol 2004

Survie après colpo-hystérectomie élargie pour cancer du col stade: coelio vs laparotomie Nam noted that overall survival was poorer after laparoscopy for locally advanced stages of cervical cancer and suggested that laparoscopy should be restricted to early stages disease. Although laparoscopic management appears a safe option, this underlines the need for prospective trial comparing laparoscopy and laparotomy. Nam et al Gynecol Oncol 2004

CHE par voie laparoscopique pour cancer du col de stade IB1: Expérience de Tenon 52 patientes (50 ans; 29-77 ans) opérées entre 2001 et 2006. Durée opératoire: 157 mn (120-240 mn). 45 CHE, 4 Amreich-Schauta, 3 trachélectomies élargies 17% de métastases ganglionnaires. Complications per-opératoires: 7% (plaie vésicale, saignement per-opératoire et plaie des gros vaisseaux avec laparoconversion). Complications post-opératoires immédiates: 9%. Abcès essentiellement.

Etude randomisée comparant la stadification clinique et coelioscopique Lai et al., Gynecol Oncol 2003

Risques de la coelioscopie Challan-Belval & Daraï, Gynecol Oncol 2006

Artifices chirurgicaux pour diminuer la morbidité de la colpohystérectomie Transposition ovarienne. Préservation du plexus hypogastrique inférieur. Réduire les indications des lymphadénectomies: Procédure du ganglion sentinelle. Clarifier les indications de paramétrectomie.

Incidence des métastases ovariennes associées au cancer du col utérin Shimada et coll, Gynecol Oncol 2006

Procédure du ganglion sentinelle Gil-Moreno et al, Gynecol Oncol, 2005

BJOG, 2005

Facteurs déterminants de l’envahissement paramétrial Steed et al, Gynecol Oncol 2006

Indication chirurgicale CancerEst pour les cancers du col de stade Ib2 ou II curage pelvien et lombo-aortique coelioscopique premier et radiochimiothérapie concomittante - chirurgie complémentaire si N(-) - radiochimiothérapie concomittante exclusive si N(+)

Curage pelvien et lombo-aortique premier pour stade Ib2 ou II: Expérience de Tenon 25 patientes (âge moyen 48 ans) entre 2001 et 2006. Durée opératoire: 204 mn (120-250 mn). Aucune laparoconversion. Nb moyen de gg en lombo-aortique 13 et 14 en pelvien. Durée moyenne d’hospitalisation 3j (2 à 5j) 15/25 avec métastases ganglionnaires dont 2 pelvien et lombo-aortique aucun lombo-aortique isolé. Complications per-opératoires: saignement 3 cas. Complications post-opératoires immédiates: 1 ascite chyleuse,. 1 abcès traité par antibiotique.Complications tardives: 2 lymphocèles, 10 CHE secondaires: fistules urétérales (n=3) et fistule recto-vaginale (n=1).

Facteurs de risque de récidive Rouzier et coll, Eur J Surg Oncol 2005

Résultats histologiques après radio-chimiothérapie concomitante néo-adjuvante Houvenaeghel et coll, Gynecol Oncol 2006

Indications de la trachélectomie Stage IA1 avec emboles vasculaires. Stage IA2 ou IB1 ≤ 2 cm. Pas d’envahissement de la partie haute du canal cervical. Pas d’atteinte ganglionnaire. Lésion exophytique pure < 3 cm Since the first report of radical trachelectomy by Dargent, the indications have been clarified. Only women with etc are good candidates for radical trachelectomy.

Caractéristiques des patientes ayant eu une trachélectomie Recently, in a large series, Plante and Roy reported a renouncement to radical trachelectomy in 10 out of 82 women. The sole difference between the two groups was a higher rate of grade 3 tumours in women who underwent a renouncement to the radical trachelectomy. Plante et al, Gynecol Oncol 2004

Cause de renoncement à la trachélectomie The reasons for renouncement, were a positive margins in 5 cases and pelvic positive nodes in 4 cases. In our experience, 3 women required a second operation after first radical trachelectomy for pelvic node metastases in 2 cases and for positive margins in 1 case not diagnosed by intra-operative histology. Plante et al, Gynecol Oncol 2004

Complications de la trachélectomie. Five major intra-operative complications were reported during radical trachelectomy. Among them, 3 required a conversion to laparotomy. As for radical hysterectomy, the main post-operative complications of radical trachelectomy were related to bladder dysfunction. Plante et al, Gynecol Oncol 2004

Faisabilité, récidives et mortalité de la trachélectomie In a review including 319 women who underwent a radical trachelectomy, recurrence and mortality rates appear acceptable ranging between 0 and 7.3%, and 0 and 4.2%, respectively. In addition, it is important to note that the rate of renouncement to radical trachelectomy was about 10%. Therefore, women have to be informed on this risk.

Sites de récidives après trachélectomie Recurrence locations were mainly nodal and represented more than one third of all recurrences followed by parametrial recurrences. In our experience, one ovarian recurrence 18 months after first treatment occurred in a woman with stage IB1 adenocarcinoma of 11 mm of diameter with negative margins and pelvic lymph nodes raising the issue of trachelectomy for adenocarcinoma. However, in the review of Plante and Roy, adenocarcinoma did not appeared a risk factor for recurrence. histology of the tumour did not appeared a criterion to exclude women from conservative management.

Fertilité après trachélectomie In addition to the recurrence rate, main end-points for radical trachelectomy are pregnancy rate and reproductive outcome. The mean conception rate reaches 45%. With a birth rate of 58% due a high rate of foetal losses during the second trimester of pregnancy.

Taux actuariel de conception après trachélectomie (95% CI) Bernardini noted that 95% of pregnancies were obtained in the 36 months following radical trachelectomy. Bernardini et al, Am J Obstet Gynecol 2003

Gynecol Oncol, 2006

Conclusion Laparoscopic radical hysterectomy for cervical cancer offers similar DFS and OS than laparotomy. Indications for locally advanced stages remains controversial. Radical trachelectomy is a safe option to spare fertility with an acceptable recurrence rate.

Pelvic lymph node metastases in cervical cancers

Vaginal radical trachelectomy Schlaerth et al, Am J Obstet Gynecol 2003

Vaginal radical trachelectomy Schlaerth et al, Am J Obstet Gynecol 2003

Abdominal radical trachelectomy Rodriguez et al, Am J Obstet Gynecol 2001

Abdominal radical trachelectomy Rodriguez et al, Am J Obstet Gynecol 2001

Retroperitoneal drainage after paraaortic lymphadenectomy Morice et al, Obstet Gynecol 2001

Disease-free survival after LARVH according to tumor stage Hertel et al, Gynecol Oncol 2003

Risk factors for recurrence after radical hysterectomy

Survival after trachelectomy and renouncement for trachelectomy Plante et al, Gynecol Oncol 2004

Radical trachelectomy Whatever the series, the mean follow-up remains short. The rate of recurrence ranged between 0 to 8.3%.

Proposal for management of women with Stage IB2 / II Abdomino-pelvic MRI or CT scan Suspicious PA nodes Absence of suspicious PA nodes Radioguided percutaneous puncture Positive PA nodes Negative PA nodes Initial Para-aortic lymphadenectomy Positive PA nodes Negative PA nodes External pelvic+ PA radiation therapy (45 Gy) with concomitant chemotherapy (cisplatin 40 + brachytherapy (15 Gy)