Cervixcancer. Vad är aktuellt? Jan Persson. Lund. Docent överläkare Dep of OB&G Skane univ hosp Lund Sweden

Transcription

1 Cervixcancer Copyright Jan Persson Lund Vad är aktuellt? Jan Persson Docent överläkare Dep of OB&G Skane univ hosp Lund Sweden

2 Controversies Preop selection related stage ( stage 1b1>= 2 cm) Neoadjuvant chemotherapy / preop downstaging Nerve sparing techniques New classification Piver / Querleu-Morrow? Use of PET CT / PET pos nodes / extent of LND Sentinel node technique, pat selection Micrometast / extent of LND Adequate margins / postop adj treatment TMMR technique / Höckel technique

3 Our patient selection for surgery of cervical cancer Stage 1a2 to 1b1<2 cm Querleu Morrow type B2 radical hysterectomy Stage 1B1 >2 cm Selected 1B2 and 2A Querleu Morrow type C radical hysterectomy hyst Fertility wish < 2m tumor = robotic radical trachelelomy Morbid obesity Adhesions Do not contraindicate Severe comorbidity Large uterus / narrow vagina Clear cell / neuroendocrine ca May contraindicate The robot facilitates Individualized treament tailored radicality

4 Sentinel node technique Nervesparing technique Fertility sparing surgery Economy Survival and recurrence pattern

5 Problems with the use of SLN techiques for cervical and endometrial cancer Copyright Jan Persson No standardization Injection sites Doses Volumes Types of tracers Timing

6 Jan Persson Riyadh/ London / Barcelona How is a sentinel lymph node defined? Copyright Jan Persson Node closest to the uterus/ side? First node in each compartment/ side? How to define those compartments? How radioactive / how much dye? Which time from injection? How many nodes are def as SLN s? How to define paraaortic SLN? Which injection site/s? Surgeons learning curve? Anatomical variations?

7 Physics behind it. Copyright Jan Persson Fluorescence is the emittance of light of a longer wave length (lower energy) than the absorbed incoming light Indocyanine green (ICG) fluoroscences with 830 nanometer light if 803 nanometer light is absorbed so how come it appears green. Jan Persson 2013 SFOG 2014

8 Issues of importance Copyright Jan Persson How is a sentinel lymph node defined? -The first/ closest to cervix if more than one.. on each side The obvious ones!!!

9 Cervical cancer Radikal hysterektomi Pelvic LND Nerve sparing techniques Symp PS

10 Copyright Jan Persson Gynecol Oncol Aug 28.. [Epub ahead of print] Reproducibility and accuracy of robot-assisted laparoscopic fertility sparing radical trachelectomy. Persson J, Imboden S, Reynisson P, Andersson B, Borgfeldt C, Bossmar T.

11 Robotic radical trachelectomy Time for surgery Circles= conversion to a Radical hysterectomy Vaginal radical trachelectomy Time for surgery

12 Distance from the cerclage to the cervical inner os

13 Pregnancy after robot assisted abdominal trachelectomy 8 out of 10 women with an active wish to conceive spontaneously pregnant resulting in 9 pregnancies one legal abortion two first trimester miscarriages, six singleton one twin pregnancy All babies (n=8) delivered at or after 35 completed weeks 13

14 Robot specific costs (EURO) Fixed cost = based on 7 year depreciation including annual maintenance Robot instruments - robot draping cost per operation Fixed cost and instruments costs shall be added Nfnnf /OP nnfn Fixed cost Annual number of operations

15 Economy on robotic radical hysterectomy in Lund OR minute charge = 17 (167SEK) 2 hours use of OR equals robot cost Copyright Jan Persson Inpatient day charge = 400 (400=SEK) 4.8 days equals robot cost

16 ROBOT-ASSISTED LAPAROSCOPIC RADICAL HYSTERECTOMY AND PELVIC LYMPHADENECTOMY : A HOSPITAL COST ANALYSIS. Pétur Reynisson MD, Jan Persson MD PhD Associate professor Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden. Objective. To compare robot-assisted laparoscopy and laparotomy for radical hysterectomy and pelvic lymphadenectomy in terms of hospital costs readmission Initial stay 5 3h Days Open Robot 1-30 Robot Robot Robot Robot Robot Skin to skin surgical times for all surgeons in chronological order institutional learning curve. Mean postoperative hospital stay, including all related readmissions until three months after surgery, following open or robot assisted laparoscopic (in chronological order) radical hysterectomy and pelvic lymphadenectomy. Copyright Jan Persson /unit Open Robot Robot Robot Robot Robot Robot OR time (minutes) * Post operative stay (days) * Admittance fee * Erythrocyte concentrate * Laparotomy-associated cost * Robot-associated cost ** Robot investment cost *** Robot maintenance cost Robotic instruments Total cost ( ) p- value **** < NS NS NS Conclusion Given 400 robot operations annually, and only after a substantial implementation period, it is feasible to perform robot assisted radical hysterectomy at an equal hospital cost compared with open surgery. E-published: Gynecological Oncology 2013 April 17 s

17 5 year survival of cervical cancer according to FIGO clinical stages Copyright Jan Persson 5Y survival 5Y disease free survival % pos pelvic nodes % pos paraaort nodes Overall 70% Stage Ia % % rare - Stage IB1 90.5% Stage IB2 79.5% 65-90% 17% 5-10% Stage IIA 74.8% 75-90% 32% 5-15% Stage IIB 67.4% 50-66% 30-37% 8-32% Stage IIIA 40.5% 33-64% Stage IIIB 44% Stage IVA 22.3% Stage IVB 9.3% Source; FIGO, Shingleton/orr Cancerof the cervix

18 FIGO Stage n= Copyright Jan Persson Node pos Radiatio Recurrenc n e Total 1 Year 2 Years 3 Years 4 Years 5 Years Local 0 0% 0% 0% 0% 0% IA Distal 0 0% 0% 0% 0% 0% 4% 4% DID 0 0% 0% 0% 0% 0% n= Local 7 2% 4% 7% 9% 9% 12 IB1* Distal 10 6% 8% 10% 9% 9% 25% 43% DID 8 2% 6% 8% 7% 9% *23 under staged n= Local 0 0% 0% 0% 0% 0% IB Distal 1 14% 17% 25% 0% 0% 57% 71% DID 1 0% 17% 25% 0% 0% n= Local 1 0% 10% 10% 13% 13% 2A Distal 1 9% 10% 10% 13% 13% 27% 64% DID 1 0% 0% 0% 13% 13% n=

19 Recurrence pattern for node neg cx-ca patients without adjuvant treatment following RRH n=100 Rec FIGO n= DID IA IB IB2 2 2A 3 7 Total Lung & supraclav Lung Recurrence 12 months Recurrence months Recurrence 24months Median time to recurrence 32 months (range 3-39) Recurrence rate 7% Of those 1 of 7 (14%) DID

20 Recurrence pattern for cx-ca patients with adjuvant treatment following RRH n=68 Supracla v Recur Lnn+ FIGO n= Lnn+ DID Lnn+ 0 0 IA IB IB A % Total 68 57% 9 67% Lungs Paraaort Recurrence 12 months Recurrence months Recurrence 24months Port Inguinal Median time to recurrence 10 months (range 5-25) Recurrence rate 19% 9 of 13 (69%) DID

21 Conclusion RRH for early stage cervical cancer Copyright Jan Persson Survival and recurrence comparable with FIGO data Higher % positive nodes than expected Two port site recurrences in high risk histologies Individualized follow up may be indicated Robot assisted surgery has its place only in a high volume setting

22 Thank you for your attention! Welcome to Lund for training and a complete overview of applications of robot assisted surgery in gynecology NEXT Masterclass Oct !

23 Thank You for Your attention