Cervical cancer: focus on the surgical treatment

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Surgical treatment is the best possible option for early-stage cervical cancer cure. In advanced-stage and even recurrent cancer-specific interventions also provide beneficial results. Modern surgical techniques don`t restrict their aims to removing cancer cells from the human body. Advanced methods are minimally invasive, leaving virtually invisible cosmetic defects instead of large scars and even saving the ability to give birth to a child in the future. Choosing the correct surgical technique and performing the most complex interventions provide excellent results in fighting cervical cancer.

Content

1. General principles of surgical treatment choice
2. Surgical treatment at early stages
3. Surgical treatment of advanced cervical cancer
4. Alternative options for women of childbearing age
5. Surgical treatment of recurrent cervical cancer
6. Choosing the right hospital to fight the disease

General principles of surgical treatment choice

Surgical treatment of cervical cancer is the first ever known treatment method, which came to the medical practice in the middle of the 19th century. As time went by, great advance has been made, and surgical techniques have evolved from open traumatic surgeries to laparoscopic minimally invasive manipulations. Nevertheless, surgery is still considered the golden standard for early-stage and low-risk cervical cancer treatment.

A number of surgical techniques are available now, so doctors should choose wisely in order to reach the best result.

The choice of a certain surgical method considerably depends on a few aspects:

• Size of the tumor
• Degree of stromal invasion (extension of the tumor inside the cervix)
• Degree of tumor differentiation (maturity of cells and intensity of mutation process)
• Lymphatic nodes invasion
• Spreading to pelvic organs, metastasizing

As these features finally determine the stage of cervical cancer, types of surgical interventions can be connected to certain cancer stages.

First, we will take a look at surgical treatment options at each stage, and after that, we will proceed to a more profound investigation and peculiarities of different techniques:

• Stage 0 (carcinoma in situ). This is the mildest form of cervical cancer, and some healthcare specialists even don`t consider it to be cancer at all. At this stage, atypical cells are found only on the surface of the cervix; deeper structures are totally normal. In case squamous cell carcinoma in situ is diagnosed, a doctor chooses between cryosurgery (including cold knife conization), laser surgery, loop electrosurgical excision procedure (LEEP/LEETZ), and simple (total) hysterectomy. Possible adenocarcinoma in situ interventions includes cone biopsy with active follow-up and simple (total) hysterectomy.
• Stage IA1 treatment options include cone biopsy with active follow-up (in case a woman wants to have children in the future), simple (total) hysterectomy, or radical hysterectomy in more complicated cases. When this stage of cervical cancer is diagnosed during pregnancy, most doctors choose watchful waiting, as it is safer for mother and child to have treatment several weeks after delivery.
• Stage IA2 and more advanced stages usually require complex treatment. Surgical interventions at this stage include cone biopsy, radical trachelectomy, or radical hysterectomy with lymphatic nodes removed.
• Stages IB1 and IIA1 imply radical trachelectomy with lymphatic nodes removed for those concerned about fertility. Otherwise, radical hysterectomy with lymphatic nodes removal is performed.
• Stages IB2 and IIA2 require only radical hysterectomy with affected lymphatic nodes (pelvic, para-aortic) dissection. Surgery is no more intervention of the first choice at this stage.
• Stages IIB, III, IVA, and IVB don`t require any type of surgical intervention at all.

Recurrent cervical cancer is a special condition. The term “recurrent” means that cancer came back after previous successful treatment. The new tumor may be detected in the cervix, uterus, or other pelvic organs.

In such cases, surgical treatment includes pelvic exenteration – during the procedure doctor removes all affected organs and tissues. When recurrent tumors arise in distant organs (e.g., bones, lungs), other types of surgical interventions are considered.

Surgical treatment at early stages

Generally speaking, total or radical hysterectomy with additional removal of lymphatic nodes is considered the most comprehensive and effective surgery in women with cervical cancer. Nevertheless, in young women who want to maintain fertility and are planning pregnancy, less radical types of surgery may also be beneficial.

Timely diagnosis and early beginning of treatment allow for saving the uterus and reproductive ability. The surgeon must be accurate enough to find the optimal balance between removing all oncological cells and preserving reproductive function.

Squamous cell carcinoma in situ and adenocarcinoma in situ affect only the superficial layer of cervical cells. Treatment of these conditions consists of destroying pathologically changed cells rather than removing them.

There are a few safe and effective options for providing this:

• Cryosurgery (other names are cryotherapy and cryoablation) is an outpatient intervention. The principle of cold temperature application lies in the basis of this procedure that destroys pathological cells or even small tumors. The manipulation is performed under the local anesthesia or even without administering anesthetic drugs. During the procedure, the surgeon applies liquid nitrogen or argon gas directly to the affected region of the cervix. As only “bad” cells are exposed to cold, surrounding tissues, remain undamaged. The surgeon may repeat the procedure a few times if necessary.
• Laser surgery is also an outpatient procedure, but it requires local anesthesia performing. With the help of a focused laser beam, a doctor burns off (vaporizes) abnormal cells from your cervix. The basic principle of this intervention consists of the influence of high temperatures and high-energy light. In addition, he may take a tissue sample for further laboratory examination – histological study.

Conization is a more traumatic group of methods, as it implies removing a cone-shaped piece of tissue from the cervix. This procedure pursues a few goals: removing oncological or suspicious oncology locus and receiving a sufficient amount of the material for comprehensive histological examination.

There are few technical ways of performing conization:

• A cold knife cone biopsy is usually an outpatient procedure; it lasts no more than an hour. During the procedure, the cervix is damaged, and this organ has an intensive blood supply. That is why a surgeon uses a special tool to seal blood vessels and stop bleeding or places few stitches on damaged areas. This intervention is performed under general or regional anesthesia. You will need to stay in the clinic until the bleeding stops and anesthesia action is over, but you will go home the same day.
• Loop Electrosurgical Excision Procedure or Large Loops Excision of the Transformation Zone (LEEP or LEETZ procedure) is highly similar to cold knife cone biopsy. The only difference is the mechanism of tissue sample taking – LEEP/LEETZ uses a low-voltage electrical current. Such technique provides the same result, namely, a good quality tissue sample for histological examination, but causes less bleeding. LEEP/LEETZ is also used for micro-invasive cervical cancer removal.

Histological examination of the removed tissue is extremely significant. This study establishes the nature of the tissue – benign or malignant. Another important moment is the presence of oncological cells on the outer edges of the sample (“negative or positive margins”). Revealing “positive margins” means that some abnormal cells may have been left in the cervix. In such a situation, the doctor will recommend you additional treatment.

Treatment of early-stage cervical cancer with cryosurgery, laser surgery, cold knife cone biopsy, or LEEP/LEETZ cures up to 90% of women, which is a quite good result. Interventions have certain side effects, like pain in the pelvis, bleeding, or watery discharge, but all of these reactions are not life threatening and usually don`t require additional treatment.

 

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Surgical treatment of advanced cervical cancer

When cervical cancer is diagnosed at stages from IA1 to IIA2, the most appropriate treatment option is hysterectomy. During a hysterectomy, a surgeon removes the uterus with its cervix and other parts of the reproductive system (optionally, depending on the results of preoperative examination).

Hysterectomy is a more serious surgical intervention, so you will need to stay at the hospital for few days. General anesthesia will help to avoid pain during the procedure. In case the hospital is properly equipped, surgeons perform hysterectomies with the help of different techniques.

The diversity of approaches makes surgical interventions more individual and helps in avoiding cosmetic defects:

• Abdominal hysterectomy, when the uterus is removed through the incision in the lower part of the abdomen or down from the belly button.
• Vaginal hysterectomy, when the uterus is removed through the vagina.
• Laparoscopic hysterectomy, when the uterus is removed through tiny cuts in the abdomen with the help of special instruments. No large cut in the abdomen is required in such a case.
• Robotic-assisted hysterectomy is a kind of laparoscopic hysterectomy when the uterus is removed through a minimally traumatic laparoscopic approach with the help of special tools connected with robotic arms.

As mentioned before, cervical cancer treatment may require removing not only the uterus but also the ovaries, fallopian tubes, and lymphatic nodes.

Based on the volume of surgical intervention, there are two main types of hysterectomy:

• Simple (total) hysterectomy. This type of surgery affects only the uterus and its cervix. The surgeon usually removes not only the sole tumor but also a certain amount of healthy tissues. If the incisions are done close to the visible tumor edge, there will be a chance of leaving a certain amount of cancer cells in the organism. The ovaries and fallopian tubes are usually preserved unless there are other medical indications for removing them.
• Radical hysterectomy is a more extensive intervention. In this case, the surgeon removes the uterus and its cervix, the upper part of the vagina, tissues next to the uterus, and pelvic lymphatic nodes. The ovaries and fallopian tubes are removed in the presence of clinical indications. Surgeons prefer to preserve the hormone-producing function of the ovaries in women of childbearing age, as this will prevent several side effects. As radical hysterectomy is usually performed in women with more advanced cancer, it is usually a part of a complex treatment scheme (e.g., in combination with chemotherapy or radiation therapy).

After the surgery, you will need to stay at the hospital for few days in order to undergo postoperative examination and be sure that you don`t have any complications of treatment.

Possible complications include the following:

• Lower abdominal pain due to tissue trauma during the surgery, skin incisions, etc.
• Difficulty with urination due to removing of certain nerves
• Bleeding, as the uterus has a good blood supply
• Wound infection, which is actually a rare complication
• Swelling of arms and legs due to excessive water retention
• Damage to the intestinal system due to scar tissue formation

After the hysterectomy, women are no longer able to menstruate and have children. Nevertheless, the surgery doesn`t influence the quality of sexual life, as women don`t need a uterus to reach orgasm.

Quite the contrary, avoiding cervical cancer symptoms (e.g., pain, bleedings) with the help of surgery actually improves a woman's sensitivity and sexual life.

 

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Alternative options for women of childbearing age

Treatment approaches in patients with “intermediate” stages of cancer are highly individual. For example, at stages IA2, IB1, and IIA1, cancer is already not superficial. The tumor invades the inner part of the cervix and can even affect nearby lymphatic nodes. On the other hand, the risk of distant metastases presence is insignificant and total removal of the tumor is possible. In such circumstances, doctors take into consideration the age of a woman and her wish to plan pregnancy in the future. In older women, total or radical hysterectomy is usually performed, as it is a simple and comprehensive intervention. The most preferred technique for younger women is radical trachelectomy.

It should be noted that radical trachelectomy is not a common intervention; it can be performed in a limited number of hospitals worldwide. Usually, radical trachelectomy is performed through the vagina; other options are the abdominal approach and laparoscopy. Of course, it is an inpatient surgery, so you`ll need to stay at the hospital for few days. The intervention is painless, as general anesthesia is provided to all patients. During the procedure, the surgeon removes the affected cervix, nearby tissues, and the upper part of the vagina. This means that the uterus stays undamaged and preserves its function. After removing obviously affected tissues, the surgeon proceeds to examine and removing of lymphatic nodes. Usually, lymphatic nodes near the cervix and uterus are removed in order to prevent relapse of the disease.

The final part of radical trachelectomy includes reconstruction of the uterus opening, as the cervix has already been removed. The surgeon places a "purse-string" stitch or a band to create a new artificial opening in the uterus. This gives a chance for both getting pregnant and carrying a pregnancy to a term. It should be noted that radical trachelectomy increases the risk of miscarriage, as fixing stitch may change its properties during a pregnancy. Natural childbirth becomes impossible, as well; the baby will need to be delivered by cesarean section.

Nevertheless, radical trachelectomy is a decent chance for preserving fertility and getting rid of cancer at the same time. The risk of relapse after this intervention is very low.

Surgical treatment of recurrent cervical cancer

When cancer symptoms arise again after the period of remission, and medical examination confirms returning of the disease, we speak about recurrent cervical cancer. Relapse of the disease may arise in the cervix or uterus, in any pelvic organ, or remote organs (in the form of metastases). Comprehensive surgical treatment, namely, pelvic exenteration, is offered if the cancer hasn`t spread beyond the pelvis.

Pelvic exenteration is an extensive surgery performed under general anesthesia. During the pelvic exenteration, the surgeon removes all affected by oncological process organs – cervix, vagina, uterus, surrounding tissues, and lymphatic nodes; bladder and intestines are also removed if they have signs of the disease. If you are planning to undergo this type of surgery, you will need to stay at the hospital for 5-10 days.

Thus, surgery involves two stages. The first one is the removal of organs and tissues, and the second one is reconstructive surgery.

During the reconstructive stage surgeon restores the function of removed organs and makes all the efforts to improve the quality of the patient`s life:

• If the bladder is removed, the surgeon creates a new way of storing and removing urine. A small part of your intestine may serve as a new bladder, which is the most widespread technique. The new bladder is connected directly to the abdominal wall so that the patient may drain the urine through the urostomy (small hole in the abdominal wall). The other option is draining urine into a small plastic bag, which is always connected to the abdomen. Before discharge from the hospital, a patient receives all the information about living with a new bladder. This requires certain skills but finally appears to be not that complicated.
• If a part of the intestine is removed, the surgeon creates a new way for defecation. The technique is similar to the abovementioned – the intestine is attached to the abdominal wall so that excrements pass through a hole in it (colostomy) to a small plastic bag connected to the abdomen. If possible, organ-saving treatment is provided, and a surgeon removes the affected part of the intestine by reconnecting the ends of healthy parts.
• If the vagina is removed, the surgeon creates a new vagina out of the patient`s own tissues. This type of plastic surgery requires specific skills and should be performed only by trained professionals.

It takes about six months to recover from pelvic exenteration completely. During this period, you will be followed up by a multidisciplinary team of healthcare professionals, which usually includes a surgeon, clinical or medical oncologist, pathologist, radiologist, gynecologist, psychologist, and social worker. You should tell your doctor about any unpleasant feelings or disturbing symptoms without hesitation. Also, you should feel free to ask all the important for your questions.

Choosing the right hospital to fight the disease

The next logical step after establishing the diagnosis and determining the volume of the operation is choosing a hospital that is even more importantly appropriate, personally for your surgeon. Actually, the result of each surgical intervention can`t be predicted for sure and considerably depends exactly on the skills and clinical experience of the surgeon. The doctor should perform delicate work on organ-saving intervention and remove all cancer cells simultaneously, as this further influences the quality of life. If we are talking about more extensive surgeries, doctors should have additional experience in surgical vagina reconstruction.

Each healthcare professional has its success rate, reflecting the general number of surgeries per year, number of excellent surgeries, and frequency and types of postoperative complications. You may check this information with data on doctors' scientific achievements, participation in medical societies, conferences and workshops, and so on. Beyond all doubt, you may choose the doctor not only in your native country but all over the world, as well. In this situation, you should be prepared in advance, as international patients have special conditions for receiving treatment – long queues for non-citizens, additional fees for insurance, problems in communication with administrative staff and the doctor himself.

The most appropriate option for arranging treatment abroad is using the help of the company Booking Health. Booking Health is a medical tourism company that annually helps thousands of cervical cancer patients receive surgical treatment abroad.

Booking Health offers help in such significant aspects as:

• Recommending the best doctor and clinic for your case
• Booking an appointment on the convenient date
• Organizing comprehensive preoperative examination
• Organizing surgical intervention and staying in the hospital as long as you need
• Providing you with the transfer, interpreter, and medical coordinator, if necessary
• Preparing for you all the medical reports and further recommendations
• Providing help in further treatment or rehabilitation, if necessary
• Providing help in further communication with your treating physician, if necessary

To start planning your surgery abroad, you should leave the request on the website of Booking Health. Our patient case manager or medical advisor will contact you the same day to discuss all the details. The aim of our work is to help you in restoring and maintain your health.

 

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Choose treatment abroad and you will for sure get the best results!

 

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Authors:

The article was edited by medical experts, board certified doctors Dr. Vadim Zhiliuk, Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

 

Sources:

National Cancer Institute

Cancer Research Institute

Sience Direct

 

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