Tratamento cirúrgico do câncer invasivo do colo uterino

Artur Lício - 2013

Carcinoma in situ do colo uterino

Carcinoma invasivo do colo uterino

Carcinoma do colo uterino Estadiamento (FIGO)

• Estádio I

• Estádio II

• Estádio III

• Estádio IV

Estádio I: Ia – O câncer invasor é identificado somente microscopicamente. Todas as lesões macroscópicas, ainda que com invasão superficial, são do estádio Ib. Ia1 – A invasão do estroma em profundidade não excede 3 mm e não é maior que 7 mm de extensão. Ia2 – A invasão do estroma mede entre 3 a 5 mm de profundidade e não excede os 7mm de extensão. Ib – Lesões clínicas limitadas ao colo do útero ou lesões pré-clínicas maiores que o estádio clínico Ia. Ib1 – Lesões clínicas até 4 cm de tamanho. Ib2 – Lesões clínicas maiores que 4 cm de tamanho.

ESTADIAMENTO

Tratamento do carcinoma de colo ECIA1

• CONIZAÇÃO

• HISTERECTOMIA SIMPLES

(CASOS SELECIONADOS)

Profundidade de

invasão (mm)

Nº de pacientes Metástases

linfonodais

Nº %

0 - 4,9 97 1 1

5 - 9,9 153 19 12,4

10 – 14,9 169 44 26

15 a 19,9 96 31 32,3

Carcinoma do colo uterino Invasão tumoral x metástases linfonodais

Inoue T. Cancer 1984;54:3035

Gynecol Oncol. 1989 Jun;33(3):265-72. Follow-up study of 232 patients with stage Ia1 and 411 patients with stage Ia2 squamous cell carcinoma of the cervix (microinvasive carcinoma). Kolstad P. Source Department of Gynecologic Oncology, Norwegian Radium Hospital, Oslo. Abstract This report retrospectively analyzes 643 patients with microinvasive squamous cell carcinoma of the cervix who were followed-up for 3-17 years. The cases were classified according to the FIGO definition adopted in 1985 which

includes a subdivision into Stage Ia1 and Stage Ia2. It is concluded that the new FIGO system has definite advantages for the decision of therapy in microinvasive carcinoma. Unnecessary radical treatment can be avoided

Gynecol Oncol. 1993 Nov;51(2):193-6. Cervical conization as definitive therapy for early invasive squamous carcinoma of the cervix. Morris M, Mitchell MF, Silva EG, Copeland LJ, Gershenson DM. Source Department of Gynecologic Oncology, University of Texas M. D. Anderson Cancer Center, Houston 77030. Abstract Young women who present with stage Ia carcinoma of the uterine cervix may strongly desire preservation of fertility. There is little published information on the outcome of patients treated for early invasive cervical cancer with cervical conization. Patients were considered eligible for conservative management if they had a squamous lesion invading to a depth less than or equal to 3 mm with no lymphatic or vascular space involvement and negative margins. We identified 14 patients who had been treated by cervical conization alone for early invasive carcinoma of the cervix. Pathologic variables were reviewed for all patients. Patient records were retrospectively reviewed for demographic, pathologic, and follow-up information. The mean depth of invasion was 1.6 mm (range, 0.5-2.8 mm). The mean number of cone sections evaluated was nine (range, 6-13 sections). The median follow-up period following conization was 26.5 months (range, 1-170 months). One patient underwent subsequent hysterectomy and was found to have mild dysplasia. Thirteen patients have retained their uteri and none has developed recurrent invasive or

preinvasive lesions. We conclude that cervical conization is an acceptable therapy for selected cases of microinvasive squamous carcinoma of the uterine cervix. Larger studies of this patient group are indicated to confirm the safety of conization as definitive therapy in selected cases of early invasive

cervical carcinoma

TRATAMENTO DO CARCINOMA DE COLO ECIA1

“ A INFILTRAÇÃO LINFOVASCULAR POR CÉLULAS NEOPLÁSICAS É CONSIDERADO UM FATOR PROGNÓSTICO IMPORTANTE PARA RECIDIVA TUMORAL”

Buckley e cols., Gynecol Oncol, 1996: 63

Considerações sobre o tratamento do adenocarcinoma de colo uterino

Tratamento do carcinoma de colo EC IA2

• “As taxas de metástases linfonodais variam de 5 a 13%”

• A presença de infiltração linfovascular por células neoplásicas induz a uma maior taxa de recorrência

Obstet Gynecol. 1988 Sep;72(3 Pt 1):399-403. Superficially invasive squamous cell carcinoma of the cervix. Maiman MA, Fruchter RG, DiMaio TM, Boyce JG Source Department of Obstetrics and Gynecology, State University of New York--Health Science Center, Brooklyn. Abstract

A series of 117 women with histologically defined, superficially invasive (1-5 mm) squamous cell

carcinoma was evaluated to determine important histomorphologic variables, frequency of pelvic lymph node metastases, and outcome. Radical or modified radical hysterectomy with pelvic node dissection was usually performed for women with more than 1 mm invasion, whereas more conservative surgery was used when invasion was 1 mm or less. Depth of stromal invasion was the

most important variable in predicting pelvic lymph node metastases. The overall incidence of pelvic node metastases was 5%, and the incidence of metastases in those patients with 3 mm or less and 3.1-5.0 mm of invasion was 2 and 13%, respectively. Although the risk of node metastases was significantly higher with deeper

invasion, one patient with 2 mm of invasion had pelvic node involvement. Microscopic lymph-vascular invasion and degree of lateral spread of tumor were also associated with lymph node metastases, whereas tumor grade was not. There were no invasive

recurrences in the series. We conclude that histomorphologic variables other than depth of stromal invasion should be considered when evaluating patients with superficially invasive squamous cell carcinoma of the cervix. We recommend that any trends toward less radical therapy for this disease be justified by equal cure rates and careful pathologic review

Tratamento do carcinoma de colo ECIA2

Histerectomia total ampliada (Piver tipo II) com linfadenectomia ilíaca

OBS. A RADIOTERAPIA EXCLUSIVA APRESENTA RESULTADOS TERAPÊUTICOS SEMELHANTES

Estádio I: Ia – O câncer invasor é identificado somente microscopicamente. Todas as lesões macroscópicas, ainda que com invasão superficial, são do estádio Ib. Ia1 – A invasão do estroma em profundidade não excede 3 mm e não é maior que 7 mm de extensão. Ia2 – A invasão do estroma mede entre 3 a 5 mm de profundidade e não excede os 7mm de extensão. Ib – Lesões clínicas limitadas ao colo do útero ou lesões pré-clínicas maiores que o estádio clínico Ia. Ib1 – Lesões clínicas até 4 cm de tamanho. Ib2 – Lesões clínicas maiores que 4 cm de tamanho.

ESTADIAMENTO

ECII

IIa IIb

Tratamento do câncer de colo EC Ib e IIa

• Histerectomia radical com linfadenectomia ilíaca (Piver tipo III) *

• Radio-quimioterapia concomitantes e exclusivas

* Geralmente associado com radioterapia adjuvante

Qt ou RXT neoadjuvantes?

Cirurgia + radioterapia adjuvante no tratamento do câncer de colo EC Ib e IIa

Autor (ano) Nº pacientes Sobrevida a 5 anos

Boronow e cols. (2000) 22 71,3 %

Havrilesky e cols. (2004) 72 72,0%

Bezerra e cols. (2011) 88 84,0%

Sobrevida global a 1, 2 e 5 anos de 82 pacientes submetidas à histerectomia radical (Piver tipo II) e linfadenectomia ilíaca no Hospital do Câncer de Pernambuco

Bezerra e cols. J Surg Oncol 2011, 104:255

Estadiamento

Estádio II

Carcinoma estende-se além da cérvix, mas não atinge a parede pélvica. O carcinoma pode envolver a vagina, mas não até o seu terço inferior.

IIa – Envolvimento não evidente do paramétrio.

IIa1 – Lesões clínicas até 4 cm de tamanho.

IIa2 – Lesões clínicas maiores que 4 cm de tamanho.

IIb – Envolvimento do paramétrio evidente, porém não atingindo a parede pélvica.

Tratamento do câncer de colo EC IIb

Radio-quimioterapia concomitantes e exclusivas

Sobrevida a 5 anos: varia de 53 a 65% Leung e cols. Int J Radiat Oncol Biol Phys,2007 Economus e cols. Obstet Gynecol, 1993

Int J Gynecol Cancer. 2013 Sep;23(7):1303-1310. Is Neoadjuvant Chemotherapy Followed by Radical Surgery More Effective Than Radiation Therapy for Stage IIB Cervical Cancer? Lee DW, Lee KH, Lee JW, Park ST, Park JS, Lee HN. Abstract OBJECTIVE: The primary objective of the study was to compare the survival rate of patients who had received neoadjuvant chemotherapy with that of patients who had received radiation therapy for stage IIB cervical cancer. The secondary objective was to analyze the effect of neoadjuvant chemotherapy on pathological prognostic factors. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who had received therapy for stage IIB cervical cancer. Based on the primary therapy, 192 patients were divided into 2 groups; patients in the neoadjuvant chemotherapy group (n =103) underwent a type III radical hysterectomy after completion of the neoadjuvant chemotherapy. Patients in the other group (n = 89) were treated with radiation alone or a combination of chemotherapy and radiotherapy. RESULTS: After neoadjuvant chemotherapy, the level of squamous cell carcinoma antigen, tumor size, lymph node involvement, and parametrium involvement were significantly decreased. However, 90.3% of the patients who had received neoadjuvant chemotherapy needed to have adjuvant therapy after radical surgery because of poor pathological prognostic factors. The rate of disease-free survival did not differ significantly between the 2 groups. However, the overall survival rate was significantly lower in the neoadjuvant chemotherapy group for patients who were 60 years or older (P = 0.03). The rates of disease-free survival and overall survival for patients who had a good (complete or partial) response to the neoadjuvant chemotherapy were not significantly higher than the rates for patients in the radiation therapy group. CONCLUSIONS: Although neoadjuvant chemotherapy improved pathological prognostic factors in patients with stage IIB cervical cancer, it was not sufficiently effective to decrease adjuvant therapy. Neoadjuvant chemotherapy also did not improve the rate of patient survival compared to the rate of patient survival in the radiation therapy group

Tratamento do carcinoma do colo uterino Estádio Tratamento indicado Tratamento alternativo

0 Conização Histerectomia

Ia1 Conização Histerectomia

Ia2 Histerectomia ampliada (piverII) + linfadenectomia

Rxt + QT

Ib1 Histerectomia ampliada (piverIII) + linfadenectomia*

Rxt + Qt

Ib2 Histerectomia ampliada (piverIII) + linfadenectomia*

Rxt +Qt

IIa Histerectomia ampliada (piverIII) + linfadenectomia*

Rxt + Qt

IIb Rxt + Qt Neoadjuvância + cirurgia

* Avaliar necessidade de adjuvância

Câncer do colo uterino Sobrevida global a 5 anos

• Estádio I = 80-95 %

• Estádio IIa = 64-83 %

• Estádio IIb = 58-66%

• Estádio IIIa = 45%

• Estádio IIIb = 36%

• Estádio IV = 14 %.

Distribuição de 1220 pacientes portadoras de carcinoma do colo uterino segundo o estadiamento

Bezerra e cols. An Fac. Med. Univ. Pernambuco 1996

Carcinoma de colo uterino

O prognóstico está diretamente relacionado ao estadiamento.