Cancer Therapy Vol 3, 357-358, 2005
Improper simple hysterectomy in invasive cervical cancer
Fatemeh Ghaemmaghami* and Malihe Hasanzadeh
Gynecology and Reproductive Medicine, Tehran
University of Medical Sciences
__________________________________________________________________________________
*Correspondence: Fatemeh Ghaemmaghami, Associate Professor,
Gynecologist Oncologist, Tehran University of Medical Sciences. 2nd
Floor, Department of Gynecology Oncology, Vali-e-Asr Hospital, Keshavarz Blvd.,Tehran
14194, Iran; Phone: 0098-21-6937766; Fax: 0098-21-6937321; E-mail: valrec2@yahoo.com, ftghaemmagh@yahoo.com
Summary
Invasive
cervical cancer discovered after a simple hysterectomy remains a problem.
Approximately 4-15% of invasive cervical cancers are found after an
inappropriate simple hysterectomy is performed. There are several reasons for
this suboptimal treatment of invasive cervical cancer. A 53-year old patient is
reported with histologically confirmed cervical cancer who was undergone a
subtotal hysterectomy and bilateral salpingo-oophorectomy inadvertendly at
another hospital. She had done dilatation curettage due to abnormal vaginal
bleeding 3 months prior of hysterectomy. A histological examination of specimen
from curettage suggested adenocarcinoma. So she scheduled for total abdominal
hysterectomy and bilateral salpingo-oophorectomy with concept of endometrial
cancer inadvertently. Exploration and palpation via laparotomy indicated that
the gross lesion with involved parametrium and impossibility doing total
hysterectomy. After the patient was referred to the Gynecology Oncology
Department at Vali-e-Asr Hospital, a vaginal examination showed a 4-cm
exophytic, necrotic cervical lesion. The patient was diagnosed with stage IIB
cervical cancer. Therefore, the patient was scheduled to receive chemoradiation
therapy and brachytherapy. A preoperative Pap smear and a careful evaluation of
the cervix are necessary before performing gynecologic surgery for the
management of benign or malignant gynecologic disease.
Cancer of the cervix is one of the most common
gynecological cancers and is one of the leading causes of cancer death
worldwide. It is widely agreed that very early stage disease (FIGO stage IA)
can be treated by a simple hysterectomy. However, patients with stage IB or IIA
disease should either have radical surgery or should be treated with
radiotherapy or chemoradiation therapy (Munstedt et al, 2004).
Despite the increasing effort to promote cervical
cancer screening and make it widely available, the number of patients referred
because of cervical cancer following inappropriate hysterectomy is not
decreasing. Indeed, approximately 4-15% of invasive cervical cancers are found
during an inappropriate hysterectomy (Munstedt et al, 2002, 2004).
The prognosis for patients with residual disease after
a simple hysterectomy is poor. Such patients have a lower survival rate than
patients who are treated with primary irradiation (Behtash et al, 2003).
We report the case of a patient referred for the
management of cervical cancer following subtotal hysterectomy to point out the
problems encountered in such patients.
A
53-year-old gravida 6, para 6 patients with histologically confirmed cervical
cancer was referred to the Gynecology Oncology Department of Vali-e-Asr
Hospital. She had undergone a subtotal hysterectomy inadvertently at another
hospital. Three months prior to the hysterectomy, the patient had experienced
abnormal vaginal bleeding for which she has been undergone dilatation and
curettage (D&C). A histological examination suggested malignancy and
probability of adenocarcinoma. So she scheduled for total abdominal
hysterectomy and bilateral salpingo-oophorectomy with concept of endometrial
cancer inadvertently. Exploration and palpation via laparatomy indicated that
the gross lesion also involved parametrium and impossibility doing total
hysterectomy. Histologic examinations of the specimen from the subtotal
hysterectomy revealed a large non-keratinized squamous cell carcinoma of the
cervix with involvement of the lower
segment of the uterus (2/3 inferior). A cytological examination of the tumor
after a laparotomy lavage was positive for malignancy.
Invasive cervical cancer that is discovered during a
simple hysterectomy remains a problem. Many studies have indicated that management
is suboptimal for the following reasons:
- Inadequate
evaluation of an abnormal
Pap smear of cervical biopsy; 7-21%
- Failure
to perform a cone biopsy when
necessary, 3-12%
- Failure
to perform endocervical
curettage after a cone biopsy, 10%
- Deliberate
hysterectomy for grossly
invasive
cancer, 11-25%
- Lack
of preoperative Pap smears, 7-29%
- Positive
cone biopsy margins or
unevaluated cone biopsy margins, 7-21%
- Misreading
of pathology results, 5%
- Errors
during colposcopic examination, 4%
- Emergency
operation because of
bleeding or perforation, 2-8%
- Failure
to check cytology results before
surgery, 2%
- Failure
to take a biopsy sample of a
gross cervical lesion, 2%
- Negative
cytology findings and no
clinical evidence of cancer, 19-31%
It
is widely agreed that adherence to screen guidelines and careful patient
management may help to minimize the number of suboptimal, simple hysterectomies
performed, where primary treatment has been inadequate. The most common preoperative
diagnosis in a study (Roman et al. 1992) of 145 cases was cervical dysplasia
and the greatest proportion of cases (40%) resulted from inappropriate
management of preinvasive diseases. Also it is shown (Rodolkis et al. 1992)
that the absence of preoperative cytology and inadequate evaluation of abnormal
pap smear were the main causes leading to an simple hysterectomy. Review of
data (Behtash et al.2003) suggests that most cases are avoidable if one adheres
to well-established guidelines for cervical cancer detection and management
yearly Pap smear, evaluation of abnormal Pap smear by performing colposcopy and
cervical biopsy or endocervical sampling and conization and fractional
dilatation and curettage when indicated.
However,
gynecologists must decide what the best subsequent management should be. There
are two options: (1) postoperative radiotherapy or (2) further surgery with
radical parametrectomy, upper vaginectomy and pelvic lymphadenectomy (Choi et
al, 1997). A study of the historical controls (covered more than 50 years) who
had not undergone subsequent therapy showed 5-year survival rates of 42-60%,
but survival rates fell to 16% in patients with surgical margins infiltrated by
tumor (Schmidt, 1951).
As in this patientŐs case, hysterectomies can be
inadequate for the following reasons: first, the lack of a preoperative Pap
smear; second, the misreading of pathology results; and third, failure to
carefully examine the cervix and take a biopsy specimen of the gross cervical
lesion at the time of the D and C.
We conclude that a preoperative Pap smear and careful
evaluation of the cervix are necessary before performing gynecologic surgery
for the treatment of benign or malignant gynecologic disease.
Behtash N,
Mousavi A, Mohit M, et al (2003)
Simple hysterectomy in the presence of invasive cervical cancer in Iran. Int J Gynecol Cancer 13, 177-81.
Choi DH, Huh
SJ, Nam KH (1997) Radiation therapy
results for patients undergoing inappropriate surgery in the presence of
invasive cervical carcinoma. Gynecol
Oncol 65, 506-11.
Munstedt K,
Von Georgi R, Zygmunt M, et al (2002)
Shortcmoings and deficits in surgical treatment of gynecological cancers: a
German problem only? Gynecol Oncol
86, 337-43.
Munstedt K,
Johnson P, et al (2004) Consequences
of inadvertent, suboptimal primary surgery in carcinoma of the uterine cervix. Gynecol Oncol 94, 515-520.
Rodolakis A, Diakomanolis E, Haidoloulos D,Voulgaris
Z. (1999) How to avoid suboptimal
management of cervical carcinoma by simple hysterectomy. Eur I Gynecol Oncol 20:418-22
Roman LD, Morris M, Eifel PJ, Burke TW, Gershenson DM
(1992)Reasons for inappropriate
simple hysterectomy in the presenceof invasive cancer of the cervix. Obstet Gynecol 79;485-9
Schmidt RTF (1951) Pan
hysterectomy in the treatment of carcinoma of the uterine cervix: evaluation of
results. J Am Med Assoc 146, 1310-1314.