Case ConferenceNovember 1th 2017

01-Nov-2017, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

November 1^st, 2017

Mrs Y

Occult Invasive Cervical Cancer POst Total Hysterectomy

 

I. Case Description

            A patient was referred from Fatmawati Hospital with a diagnosis of cervical cancer stage IB 2. Patient had undergone TAH-BSO on September 9^th, 2017 in Hermina Bogor Hospital with the PA result was well to moderately differentiated cervical adenocarcinoma. Then patient was referred to Fatmawati Hospital and was told that the surgery was not completed yet (the lymph glands has not been removed). Fatmawati Hospital then suggested the patient to receive radiotherapy in RSCM. Then the PA result from Hermina Bogor Hospital was reviewed in RSCM on October 9^th, 2017 with result well differentiated cervical endometrioid carcinoma with no lymphovascular invasion.

 

II.        Physical examination on October 3^rd, 2017:

A. General status:

CM. BP: 106/74 mmHg, HR: 81 x/min, T: 36 °C, RR: 20 x/min,

Head: Pale conjunctiva (-/-) icteric sclera (-/-)               

Thorax: symmetry shape and movement of hemithorax

Lung: vesicular breath sound on both lungs, no wheezing or rhales

Cardia: no murmur, no gallop

Abdomen: flat, intestine sound (+), shifting dullness (-), surgical scar (+)

B. Gynecology examination:

Inspection : Vulva and urethra was normal, no bleeding

Speculum Examination : Vaginal wall was smooth. Vaginal stump was normal, no bleeding

RVT : No mass palpated. Rectum mucosa was normal.

 

 

 

III.                 Work Up

A.    US result on October 5^th, 2017

Description: There were no visual of uterine corpus and both ovaries (post TAH-BSO). Vaginal stump was normal, neither abnormal mass nor neovascularization inside. No enlargement of bilateral paraaorta and parailliac lymph nodes. Liver and both kidneys were normal. No ascites.

Coclusion: Cervical Cancer (post TAH-BSO). Neither abnormal mass nor metastasis in the abdominopelvic was found.

 

B.     Laboratory October 6^th, 2017

- CBC :11.3/35.7/4130/233000                      

- SGOT/SGPT : 15/13

- Ur/Cr : 18/0.8                                    

- Na/K/Cl : 147/4.4/108

 

C.    Pathology Anatomy Result From Hermina on September 19^th, 2017

Macroscopic: Received 1 sac contained 1 piece uterine tissue that has been split, size 8x6x2.5cm, with a thread mark, portio (+), white with a part of brown, apart. Cervix contained tumor mass surrounding the portio, size 4x4cm, brownish, fragile.

i.            Cervix and myometrium, there was a fragile mass on cervix, brown, surrounding the portio/cervix, 4 kup 1 cassette

ii.          Left tube, size 6cm long and diameter 0.7cm with a cyst size 3x1.5x0.7cm adhered to the tube, and ovarium size 1x0.5x0.5cm, 3 kup 1 cassette

iii.        Right tube, size 1.5cm long and diameter 0.5cm, no ovarium, 1 kup 1 cassette

iv.        Border of vaginal incision 1 cassette

v.          Parametrium 1 cassette

Microscopic: Preparations from the uterus and cervix showed malignant epithelial tumor arranged tubular and micropapillary, and infiltrating myometrium. Tumor cell size were varying, with pleomorphic nucleus, hyperchromatic, vesicular, partially with clear nucleolus, eosinophilic cytoplasm. Mitosis was hard to found. Moderate lymphocyte reaction. Desmoplastic stromal was covered by acute and chronic inflammatory cells with necrotic area and bleeding. No lymphovascular invasion was found. Endometrium was in proliferation phase. No tumor cell was found in both tubes and left ovarium. No tumor cell was found in the border of vaginal incision and parametrium.

Conclusion: Histology accordance to well to moderately differentiated Cervical Adenocarcinoma pT2NxMx

 

D.    Pathology Anatomy Result on October 23^rd, 2017 (RSCM)

Macroscopic: Received 7 slides PA no. 17090033

Microscopic: Reviewed 7 slides PA no. 17090033, A, B, C, I, II, cut into pieces (2 slides) from Hermina Bogor Hospital.

i.            Slide A with cervix and myometrium note showed the cervical tissue contained malignant epithelial tumor mass arranged papillotubular and glandular, infiltrating between the connective tissue. Tumor cell was large, pleomorphic, hyperchromatic, vesicular, partially with clear nucleolus. Eosinophilic cytoplasm. Mitosis was found. Fibrotic stromal was mildly covered by chronic inflammatory cell. Deepest invasion from this preparation can’t be determined. No tumor cell was found in the lymph nodes. Endometrium preparation showed that endometrium tissue covered by single layer columnar epithelium. Endometrium gland was covered by single layer cuboidal epithelium with cellular stromal. Myometrium consisted of interlacing smooth muscle with blood vessels between them.

ii.          Slide B with left tube and left ovarium note, left tube/left fimbriae preparation consisted of tube tissue with good plica structure, covered by ciliated single layer columnar epithelium with intact muscular layer. Ovarium preparation showed ovary tissue consisted of corpus albicans.

iii.        Slide with right tube note, tube preparation showed tube tissue with good plica structure, covered by ciliated single layer columnar epithelium with intact muscular layer.

iv.        Slide I without a note, preparation showed ovary tissue (right?), probable vaginal tissue sampling, ectocervix and endocervix. Ovary tissue showed a tissue consisted of corpus albicans. Probable vaginal tissue showed tissue that covered by squamous epithelium. No tumor mass was found. Ectocervix tissue showed a tissue covered by squamous epithelium and endocervix tissue covered by single layer columnar epithelium. Endocervix glands covered by single layer columnar epithelium, partially cystic dilated covered by single layer low columnar epithelium. Endocervix tissue consisted of tumor mass.

v.          Slide II without a note, and the remaining 2 slides that were cut into pieces showed a similar tumor mass.

 

Topography:   C53.9                                      Morphology: M8380/3

 

Conclusion: Histology accordance to well differentiated cervical endometrioid carcinoma. No lymphovascular invasion was found. No tumor was found in probable vaginal wall sampling preparation.

Notes:

-    Assessment of the deepest stromal invasion can’t be performed because there’s no sampling obtained from that area.

-    Assessment of the border of vaginal incision was inadequate (not enough vaginal tissue)

-    Assessment of parametrium can’t be performed because there’s no sampling obtained from that area.

 

 

 

 

Problems to be discussed

Is parametrectomy and lymphadenectomy better than radiotherapy for patient with occult invasive cervical cancer post total hysterectomy ?

 

Clinical question in this case will be developed by PICO approach

Patient	occult invasive cervical cancer post total hysterectomy
Intervention	parametrectomy + lymphadenectomy
Comparison	radiation
Outcome	overall survival

 

 

 

 

METHODS

Search strategy

In order to answer the question above, we conduct a searching in PubMed site by using keywords, occult invasive cervical cancer post total hysterectomy AND parametrectomy + lymphadenectomy AND radiation. The search was conducted on PubMed on October, 30th 2017, there was 4 journals matched to the search terms.

 

Search strategy in PubMed conducted on

 

Engine	Search terms	Results
PubMed	occult invasive cervical cancer post total hysterectomy AND parametrectomy + lymphadenectomy AND radiation	4

 

 

 

 

 

 

 

 

Figure 1. Flowchart of search strategy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Critical Appraisal

Article 1

JY Park et al. Management of occult invasive cervical cancer found after simple hysterectomy. Annals of Oncology 21: 994–1000, 2010 doi:10.1093/annonc/mdp426

 

Article 2

F. Narducci et al. Occult Invasive Cervical Cancer Found After Inadvertent Simple Hysterectomy: Is the Ideal Management: Systematic Parametrectomy With or Without Radiotherapy or Radiotherapy Only?. Ann Surg Oncol DOI 10.1245/s10434-014-4140-5

 

	1st art	2nd art
A. Are the study results valid
1.  Was there a representative and well-defined sample patients at a similar point in the course of disease?	yes	yes
2. Was follow-up sufficiently long and complete?	yes	yes
3. Were objective and unbiased outcome criteria used?	yes	yes
4. Was there adjustment for important prognostic factors?	yes	yes
B. What were the results?
1. How large is the likelihood of the otcome events in a specific period of time?	N/A	N/A
2. How precise are the estimates of likelihood? (consider 95% CI)	100 vs 77 (p 0.04)	100 vs 93 (p 0.276)
C. Can the results be applied to your patients?
1. Were the study patients similar to my own?	yes	yes
2. Are the results useful for reassuring or counseling patients?	yes	yes
3. Is the treatment feasible in my setting?	yes	yes
D. Conclusions
1. The results or recommendation are valid?	yes	yes
2. The results clinically important?	yes	yes
3. The results are relevant to my practice?	yes	yes

 

 

 

Discussion

 

Cervical cancer is the second most common female cancer and one of the leading causes of cancer deaths in females worldwide. Most patients with early-stage cervical cancer undergo radical hysterectomy with pelvic and paraaortic lymphadenectomy, with 5-year survival rates of 75%–90%. But sometimes this malignancy is encountered after simple hysterectomy performed, due to benign gynecologic conditions or preinvasive cervical lesions. Radical parametrectomy (RP), consisting of resection of the parametrium, upper vaginectomy, and pelvic - paraaortic lymphadenectomy may be carried out as a definite treatment in these patients. However, due to technical difficulties in carrying out RP and a lack of knowledge about the safety and efficacy of this operation, physicians tend to administer radiation therapy (RT) or concurrent chemoradiation therapy (CCRT) instead.

JY Park et al performed a research to estimate safety and efficacy of radical parametrectomy (RP) and radiation therapy (RT) or concurrent chemoradiation therapy (CCRT) for patients with occult invasive cervical cancer found after simple hysterectomy. They retrospectively evaluated outcomes in 147 patients with occult invasive cervical cancer. After simple hysterectomy, presumed FIGO stage was IA1 in 48 patients (32.7%), IA2 in 7 patients (4.8%), IB1 in 85 patients (57.8%), IB2 in 4 patients (2.7%), and IIA in 3 patients (2.0%). The hysterectomy specimens from all 48 patients with IA1 lesions had negative resection margins. All patients had squamous lesions. After simple hysterectomy, none underwent further imaging. Six patients (12.5%) had positive LVSI. None of these patients underwent further treatment after simple hysterectomy. After a median follow-up time of 158 months (range 34–235 months), none of these patients had recurrent disease. Of the 99 patients with IA2–IIA lesions, 26 received no further definitive treatment, including RT, CCRT, or RP (observation/ chemotherapy group), and 44 patients received RT or CCRT (RT/CCRT group) and 29 underwent RP (RP group) as definitive treatments after simple hysterectomy. Thirty-two patients received RT and 12 received CCRT. The chemotherapeutic regimen was weekly cisplatin in one patient, paclitaxel/cisplatin in two patients, and 5-fluorouracil/cisplatin in nine patients. The 10-year DFS and OS rates were 93% and 94%, respectively. Twenty-nine patients underwent RP with pelvic lymphadenectomy. After a median follow-up of 73 months (range 3–220 months), no patient showed evidence of disease recurrence or late complications related to RP that required further management.

From this research, the finding in patients with more advanced early-stage lesions (stage IA2–IIA), a definitive treatment, such as RT, CCRT, or RP, is necessary because these patients are at increased risk of recurrence and death, although they received adjuvant chemotherapy after simple hysterectomy. Although similar survival outcomes were obtained in the RT/CCRT and RP groups, the lower rate of late complications after RP makes the latter preferable compared with RT/CCRT in this patient population. RP was feasible in all patients in our series and the operative parameters and complications were acceptable. The conclusion is the survival outcome after RP was similar to that after RT or CCRT in patient populations with similar disease stage, tumor size, positive resection margin, positive LVSI, grade of tumor, and depth of stromal invasion. In addition, RP was feasible in all patients. The immediate surgical parameters were acceptable, the rate of perioperative complications was very low, and there was no late morbidity. Due to the high rates of long-term morbidity after RT or CCRT, RP may be preferable for selected patients with IA2–IIA occult invasive cervical cancer. We think that RP may be of greatest benefit in young patients who want to preserve their ovarian and sexual function.

Narducci et al underwent a research and retrospectively analyzed 29 patients with occult cervical cancer found after inadvertent simple hysterectomy and who were referred to our cancer center between 2000 and 2010. All of the patients were discussed by the tumor board. Thirteen patients underwent surgery (radical parametrectomy and pelvic lymphadenectomy) using the minimally invasive approach (surgical group), and 16 patients underwent pelvic lymphadenectomy and radiation therapy or concurrent chemoradiation (radiation group). In the surgical group, all of the patients were managed by minimally invasive surgery. 61.6 % of the patients required only surgery and no other adjuvant therapy. In the radiation therapy group, 43.8 % of the patients had pelvic radiation, and 25 % had concomitant chemoradiation. There were a few grade I and grade II complications, but no complications of grade III or above. The 5-year overall survival and disease-free survival rates in the surgical group and radiation therapy group were 100 and 77% (p=.04), and 86 and 37% (p=.02) , respectively.

 

From these two journals, we can conclude that for patient with occult invasive cervical cancer diagnosed after total hysterectomy, parametrectomy and lymphadenectomy will be a better treatment option. But if there is probability to give adjuvant RT or CCRT after RP, then RT or CCRT should be given to the patient instead of RP, because the combination of surgery and RT is associated with high morbidity rate with no further survival benefit. From the literature, it also stated that most physicians are reluctant to carry out RP in patients with IA2–IIA occult invasive cervical cancer because they consider the RP procedure to be quite difficult, require an experienced surgeon, and be associated with a high rate of surgery-related morbidity. 

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