Editors Shalini Rajaram MD MAMS
Director Professor Department of Obstetrics and Gynecology University College of Medical Sciences and Guru Teg Bahadur Hospital
Delhi, India
K Chitrathara MD (OBGYN) MCh (Urology)
HOD and Senior Consultant Department of Surgical and Gynecologic Oncology Lakeshore and Welcare Hospitals
Kochi, Kerala, India
Amita Maheshwari MD
Associate Professor Department of Gynecologic Oncology Tata Memorial Hospital
E Borges Marg, Parel Mumbai, Maharashtra, India
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Cervical Cancer: Contemporary Management
First Edition: 2012
9789350255827
Printed at
5Dedicated to
Our patients and teachers who have taught us all that
we know about Cervical Cancer
and
Our students for whom we hope that this book
will be a valuable tool in furthering knowledge and skills in the
management of this disease
7CONTRIBUTORS
- Abraham Peedacayil dgo md mph mrcog
- Gynecologic Oncologist and Professor of Gynecology
- Christian Medical College
- Vellore, Tamil Nadu, India
- Alexander Peters md ph d
- Professor
- Dept of Gynecologic Oncology
- Leiden University Medical Centre
- Leiden
- The Netherlands
- Amita Maheshwari md
- Associate Professor
- Department of Gynecologic Oncology
- Tata Memorial Hospital
- E Borges Marg, Parel,
- Mumbai, Maharashtra, India
- Amit Bahl md
- Senior Research Associate
- Department of Radiation Oncology
- DRBRA Institute Rotary Cancer Hospital
- All India Institute of Medical Sciences
- New Delhi, India
- Bharat Rekhi md dnb miac
- Associate Professor
- Department of Pathology
- Tata Memorial Hospital
- Parel, Mumbai, Maharashtra, India
- Bhupesh Kumar Goyal md dnb
- Professor
- Department of Obstetrics and Gynaecology
- Command Hospital (Eastern Command)
- Kolkata, West Bengal, India
- Bindiya Gupta md
- Senior Research Associate
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- DN Sharma md
- Additional Professor
- Department of Radiation Oncology
- DRBRA Institute Rotary Cancer Hospital
- All India Institute of Medical Sciences
- New Delhi, India
- E Leblanc
- Professor
- Department of Gynecologic Oncology
- Centre Oscar Lambret
- 3, Rue Frédéric Combemale,
- B.P. 307, 59020, Lille CEDEX, France.
- GK Rath md
- Professor and Head
- Department of Radiation Oncology,
- Chief
- DRBRA Institute Rotary Cancer Hospital
- All India Institute of Medical Sciences
- New Delhi, India
- Gaurav Prakash md dm
- Department of Medical Oncology
- All India Institute of Medical Sciences
- Institute Rotary Cancer Hospital
- New Delhi, India
- Harpreet Kaur md
- Former Senior Resident
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- Hsueh Ni Lee md
- Senior Registrar
- Department of Radiation Oncology
- Tata Memorial Hospital
- Parel, Mumbai, Maharashtra, India
- JSP Somashekhar ms mch (Oncosurgery), frcs (Edinburgh) hod
- Department of Surgical Oncology
- Consultant Surgical and Gynecologic
- Oncology
- Manipal Comprehensive Cancer Centre
- Manipal Hospital,
- Bengaluru, Karnataka, India
- Jamie N Bakkum-Gamez md Fellowship Gyn Oncology (Mayo clinic, Rochester, MN)
- Assistant Professor of Obstetrics and Gynecology and Senior Associate Consultant in the Department of Obstetrics and Gynecology, Division of Gynecologic Surgery and Senior Associate Consultant, Department of Surgery
- Joseph Edison md (Radiation Oncology), dmrt
- Chief Consultant Radiation Oncologist
- Caritas Cancer Institute
- Kottayam, Kerala, India
- K Chitrathara md (obgyn) mch (Urology)
- HOD and Senior Consultant Department of Surgical and Gynecologic Oncology
- Lakeshore and Welcare Hospitals
- Kochi, Kerala, India
- K Pavithran md dm (Medical Oncology)
- Professor
- Department of Medical Oncology and Hematology
- Amrita Institute of Medical Sciences
- Kochi, Kerala, India
- KP Haresh md
- Senior Research Associate
- Department of Radiation Oncology
- DRBRA Institute Rotary Cancer Hospital
- All India Institute of Medical Sciences
- New Delhi, India
- Kedar K Deodhar md FRCPath
- Associate Professor
- Department of Pathology
- Tata Memorial Hospital
- E. Borges Marg, Parel
- Mumbai, Maharashtra, India
- Lalit Kumar md dm
- Professor
- Department of Medical Oncology
- All India Institute of Medical Sciences
- Institute Rotary Cancer Hospital
- New Delhi, India
- M Dinesh md dnb
- Professor of Radiation Oncology
- AIMS, Kochi, Kerala, India
- MA Muckaden md (Radiation Oncology),
- PG Diploma Palliative medicine, UK
- Professor
- Radiation Oncology and Officer-in-Charge Palliative Care Department
- Tata Memorial hospital
- Parel, Mumbai, Maharashtra, India
- Manoj Babu R ms dnbz (O & G)
- Fellowship in Surgical Oncology (AIMS)
- Assistant Professor
- Department of Obstetrics and Gynecology
- Govt Medical College
- Kottayam, Kerala, India
- Namory Keita md
- Professor and Head
- Department of Obstetrics and Gynaecology
- University Hospital of Conakry
- Conakry Guinée
- Namrata Kachhara ms
- Consultant, Gynecologic Oncologist
- Bombay Hospital
- Indore, MP, India
- Neelam Wadhwa md
- Reader
- Department of Pathology
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- Neha Kumar md
- Former Senior Resident
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- PK Julka md
- Professor
- Department of Radiation Oncology
- DRBRA Institute Rotary Cancer Hospital
- All India Institute of Medical Sciences
- New Delhi, India
- Parimal Jivarajani md
- Assistant Professor
- Department of Community Oncology
- Gujarat Cancer and Research Institute and MP Shah Cancer Hospital
- Ahmedabad, Gujarat, India
- Partha Basu md dnb
- Head, Department of Gynecologic Oncology
- Chittaranjan National Cancer Institute
- 37, SP Mukherjee Road
- Kolkata, West Bengal, India
- Paulo Naud md
- Head
- Screening Group and HPV Vaccine Service
- Hospital Clinicas de Porto Alegre
- University of ProtoAlegre
- 111, Petropoli/s, Porto Alegre, Rio Grande Sul, Brazil
- Peter Heintz md phd
- Professor
- The Dutch School of Gynecologic Oncology and Pelvic Surgery and
- The University of Utrecht
- Pieterskerkhof 2a
- 3512JR Utrecht
- The Netherlands
- Pulikottil Okkuru Esmy md
- Head
- Cancer Services
- Christian Fellowship Community Health Centre
- Ambillikai, Dindigul District
- Tamil Nadu, India-624 612
- R Sankaranarayanan md
- Head
- Early Detection and Prevention Section (EDP)
- Head, Screening Group (SCR)
- International Agency for Research on
- Cancer (IARC)
- 150 cours Albert Thomas, 69372 Lyon
- Cedex 08
- France
- Randeep Singh md dm
- Senior Resident
- Department of Medical Oncology
- Tata Memorial Hospital
- Mumbai, Maharashtra, India
- Reena Engineer dnb dmrt
- Associate Professor
- Department of Radiation Oncology
- Tata Memorial Hospital
- Parel, Mumbai, Maharashtra, India
- Rekha Wuntakal md dnb dffp mrcog
- Educational /Research Fellow in Obstetric and Gynaecology
- Department of Obstetrics and Gynaecology
- Whipps Cross University Hospital
- Whipps Cross Road, London-E11 1NR, UK
- Rema P md dgo
- Assistant Professor
- Department of Surgical Oncology
- Regional Cancer Centre
- Thiruvananthapuram, Kerala, India
- Santosh Menon md dnb
- Assistant Professor
- Department of Pathology
- Tata Memorial Hospital,
- Parel, Mumbai, Maharashtra, India
- Sean Dowdy md facs
- Associate Professor in Gynecologic Surgery
- Chair
- Ob/Gyn Research Committee
- Mayo Clinic
- 200 First St. SW
- Rochester, Minnesota, USA
- Shaili Nigam md
- Consultant Obstetrics and Gynecology
- Katra Hospital and Research Centre
- Mandla, MP, India
- Shalini Rajaram md mams
- Director Professor
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- Sharmila Pimple md
- Additional Professor
- Department of Preventive Oncology
- Tata Memorial Hospital
- Parel, Mumbai, Maharashtra, India
- Shilpa Kava mbbs
- Post graduate Student
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- Shyam Kishore Shrivastava md dnb
- Professor and Head
- Department of Radiation Oncology
- Tata Memorial Hospital
- Parel, Mumbai, Maharashtra, India
- Smita Joshi mbbs
- Programme Director
- Jehangir Clinical Development Centre (JCDC)
- Jehangir Hospital Premises
- Pune, Maharashtra, India
- Somanathan Thara md
- Additional Professor
- Department of Pathology
- Regional Cancer Centre
- Thiruwananthapuram, Kerala, India
- Srabani Mittal dph
- Consultant
- Reproductive and Child Health, NRHM
- Child In Need Institute
- Kolkata, West Bengal, India
- Sruthi Bhaskaran md
- Senior Resident
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- Suchetha S md dgo
- Lecturer
- Department of Surgical
- Oncology*
- Regional Cancer Centre
- Thiruvananthapuram, Kerala, India
- Sudeep Gupta md dm
- Associate Professor
- Department of Medical Oncology
- Tata Memorial Hospital
- Parel, Mumbai, Maharashtra, India
- Sumita Mehta dgo dnb mams
- Specialist
- Department of Obstetrics and Gynecology
- University College of Medical Sciences and Guru Teg Bahadur Hospital
- Delhi, India
- Supriya Chopra md dnb
- Assistant Professor
- Department of Radiation Oncology
- ACTREC, Tata Memorial Centre
- Parel, Mumbai, Maharashtra, India
- Surendra S Shastri md
- Professor and Head
- Department of Preventive Oncology
- Tata Memorial Hospital
- E Borges Marg, Parel,
- Mumbai, Maharashtra, India
- Tony Hollingworth phd frcs(ed) frcog
- Consultant Obstetrician and Gynaecologist
- Department of Obstetrics and Gynaecology
- Whipps Cross University Hospital
- Whipps Cross Road, London-E11 1NR, UK
- Twalib Ngoma md
- Director
- Ocean Road Cancer Institute
- Dar es Salaam, Tanzania
- Umesh Mahantshetty md dnb dmrt
- Associate Professor
- Department of Radiation Oncology
- Tata Memorial Hospital
- Dr Ernest Borges Marg
- Parel, Mumbai, Maharashtra, India
- Usha Rani Poli dnb(obandg) dgo
- Assistant Professor of Gynaecology
- MNJ Institute of Oncology and Regional Cancer Center,
- Hyderabad, Andhra Pradesh, India
- Vijay Zutshi md
- Senior Specialist
- Department of Obstetrics and Gynecology
- Maulana Azad Medical College and Associated Lok Nayak Jayaprakash Hospital
- Delhi, India
- Vivek Marwah ms (Gynae.and Obst),
- Dip. Op. Pelv.
- Head, Division of Minimally Invasive
- Gynaecology
- Max Super Speciality Hospital, Saket
- New Delhi, India
- Wesley M Jose md dnb (Medical Oncology)
- Assistant Professor
- Department of Medical Oncology and Hematology
- Amrita Institute of Medical Sciences
- Kochi, Kerala, India
Cancer of the cervix is a unique prototype among human malignancies. More than a half century has passed since the Papanicolaou test, which examines exfoliated cervix cells, was validated as the initial successful screening method for cancer. In countries where this screening method has been incorporated into the healthcare systems, dramatic decreases in the incidence of invasive cervix cancer have occurred. The interim decades have provided expansion of our knowledge regarding the epidemiology, early detection, pathogenesis, treatment and prevention of cervix cancer. Basic, translational and clinical investigative efforts have facilitated recognition of a viral etiology and development of vaccine technology for prevention with a vision of potentially eradicating this disease. While these advances in prevention, early detection and management of cervix cancer are noteworthy, globally more than a quarter of a million women die annually from this disease and in excess of 80 percent of these deaths occur in low- and medium-resource countries. Hence, a requisite focus persists to enhance access to care, affordability, infrastructure, compliance, and surveillance to improve outcomes in women diagnosed with cervix cancer.
Cervical Cancer: Contemporary Management is indeed a state-of-the-art textbook on cervix cancer. Although numerous general gynecologic oncology textbooks serve as practical resources for cervix cancer, out of necessity, they cannot address in depth the many critical aspects of this disease as provided in this text. The contents are organized into 8 sections and 33 chapters with the latter consistently and sequentially structured with an initial outline, introduction, descriptive but focused narrative complemented by quality figures, diagrams, tables and photographs and supported by contemporary references affording ease of access to appropriate resource information. and address the etiopathogenesis of cervix cancer including concise discussions of the viral-induced molecular events, aberrations yielding recognized histological changes, the role of screening, early detection, treatment alternatives and prevention opportunities. Notably, each of these chapters is authored by one or more physician-scientists from India. Hence, in addition to describing in detail the current high-tech approaches to prevention, screening and early treatment regarded as standard of care in high-resource settings, these authors also provide more pragmatic paradigms utilizing data-generated approaches for these interventions to maximize outcomes as a function of available resources in developing countries. and provide particulars regarding the management of invasive disease including the indications for and nuances of various radical surgical approaches and radiotherapy techniques. Additional sections include chapters dedicated to the complexities of treating recurrent disease, cervical abnormalities in pregnancy, unanticipated invasive cervix cancer at hysterectomy and the delivery of palliative care.
I wish to congratulate Drs Rajaram, Chitrathara and Maheshwari as well as the contributing authors for this outstanding edition addressing the etiology and management of the leading cause of death globally from gynecologic cancer, namely, cervix cancer.
Karl C Podratz md phd facs
13PREFACE
This book is born out of a passion for ideal management of cervical cancer, having seen the humiliation, suffering and loss of dignity of women, especially those with advanced cancers, have to endure. This may be the only book of its kind comprehensively addressing all aspects of cervical cancer beginning with screening, diagnosis and management of pre-invasive disease which includes screening in low resource countries, recent advances in screening technology, HPV carcinogenesis, molecular markers and of course primary prevention with HPV vaccination. Given the knowledge gained over the past decade, it is prudent to accept and implement primary prevention methods which we hope in the future brings down the incidence of a disease which is largely preventable.
Staging protocols, imaging techniques and sentinel node evaluation have been discussed in detail. Surgical management of cervical cancer is complete in all respects. All surgical techniques ranging from radical trachelectomy, radical abdominal hysterectomy, laparoscopic nerve- sparing radical hysterectomy, radical vaginal hysterectomy and the complications of surgery are described in detail. Emphasis in many chapters is on nerve-sparing radical hysterectomy which is known to reduce bladder, rectal and sexual dysfunction postoperatively. Postradiation hysterectomy and pelvic exenterations have been extensively covered. Videos on robotic radical hysterectomy with pelvic lymphadenectomy in addition to open and laparoscopic radical procedures and radical trachelectomy complete the surgical armamentarium. Renowned national and international surgeons have contributed well-written chapters which speak for their experience and expertise.
Likewise, the radiation arm of cancer cervix therapy is extensive and ranges from radiation therapy: principles and techniques, chemoradiation, neoadjuvant chemotherapy, management of recurrent disease by both chemotherapy and radiation and interstitial brachytherapy. Image-guided techniques and treatment planning have been described wherever appropriate. Radiotherapy, as we know, is not without complications and this has also been addressed rationally. Finally, the book ends with a few special scenarios like cancer cervix and pregnancy, management after inadvertent simple hysterectomy and palliative care which by itself is an area that requires huge inputs.
We hope this book is valuable and finds itself on the bookshelves of all those who practice gynecologic oncology, postgraduate students and fellows specializing in this field.
Shalini Rajaram
K Chitrathara
Amita Maheshwari
14ACKNOWLEDGMENTS
The editors would like to thank all the contributors—both Indian and International, for sparing their valuable time, effort and energy in contributing well-written and well-illustrated chapters which will benefit all practicing gynecologists, postgraduates and fellows specializing in the fascinating field of gynecologic oncology and hopefully translate into better practices which will ultimately benefit the patient.
We sincerely thank all contributors for videos of skilled surgical techniques which the beginner can play over and over again until he masters the technique.
Finally, the book would not have been possible without the effort of all the professionals at M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi. We thank them for their stupendous effort and for giving the book an international look.