Routes of Surgeries
Laparotomy requires an incision on the abdomen to remove the affected organs, determine the stage of cancer and to what extent the cancer has spread. Recovery from this surgery takes a bit longer than a laparoscopy.
Laparoscopy is a type of minimally invasive surgery. This technique uses a laparoscope (a small hollow viewing tube) and specialized tools that help the surgeon remove the organs through the vagina (birth canal). Typically, this leaves four very small scars, and recovery is generally considered to be much faster than regular abdominal surgery requiring a larger incision. Laparoscopy is a type of minimally invasive surgery.
In some centres across Canada, surgery may be done with the use of robotics. Robotic surgery allows the surgeon great precision, smaller incisions, less blood loss and earlier recovery time. This is an alternative form of minimally invasive surgery that may be available to you depending on where you live.
Vaginal surgery is the most minimally invasive surgery. The entire surgery is done through the vagina with no abdominal incisions. This route may not allow for all the surgery to be done; it is primarily for a hysterectomy only. Vaginal surgery is rarely done for cancer treatment.
Types of Surgeries
Cervical Excisional Procedures (Cone Biopsy and Loop Electrosurgical Excision Procedure (LEEP)
With the Cone biopsy, the surgeon removes a cone shaped piece of tissue from the cervix and cervical canal. This tissue is sent to the pathologist for review to see if any cancer is detected in the specimen. This procedure may be used to treat or diagnose a precancerous cervical condition.
The LEEP procedure is used more commonly to treat “precancerous” lesions of the cervix. LEEP uses a high-frequency electrical current to remove suspicious tissue. Large and deep sections of tissue can be removed with very high cure rates. This tissue is also sent to pathology for review.
This procedure uses a laser (a beam of intense light) to damage or remove the tumour. The laser is used as a knife to remove the tumour by burning off the tissues. With this procedure there is little to no bleeding.
In a hysterectomy, the uterus and cervix are removed. The ovaries and tubes may or may not be removed at the time of surgery. The preferred way to perform this surgery is with a minimally invasive surgery, such as laparoscopy, robotic or vaginal.
Depending on the features of your cancer, your surgeon may take a sampling of lymph nodes in the pelvis and/or along the aorta
or from the groin to send to pathology. This is called staging, and helps determine if any cancer cells have spread from their original location to the lymph nodes in these areas. The body has many lymph nodes and not all lymph nodes in the body will be removed.
Some centres use sentinel lymph node mapping to follow the drainage of the tumor area in order to sample those specific lymph nodes to assess the spread of cancer cells. This involves the injection of a radionucleotide or blue dye, into the tumour site the morning of your surgery. During the surgery, the surgeon uses a probe to find the lymph nodes that drain the area and removes them for pathology analysis. This minimizes the number of lymph nodes that are removed during the surgery, decreasing potential long-term side effects of leg swelling.
An omentectomy involves the removal of the omentum, which is a fat pad that lies over the bowel. It is the first area that cancer cells generally spread to within the abdomen. It is not a vital organ, so removing it does not cause any harm.
Debulking means the removal of as much of the tumor as possible with possible bowel resection (removing a part of the bowel and putting it back together), bladder resection (removing a part of the bladder), peritoneal stripping (removing tumour deposits off the lining of the abdominal cavity), splenectomy (removing the spleen), diaphragm stripping (removing tumour deposits off the diaphragm), and liver resection (removing part of the liver).
Radical Trachelectomy with Lymphadenectomy
A radical trachelectomy with lymphadenectomy is an option for some women who have a very early cancer and who wish to preserve their fertility. This procedure involves the removal of the cervix and its surrounding tissue, along with a sampling of lymph nodes without removing the entire uterus. A permanent stitch (cervical cerclage) is placed in the cervix to help support the lower uterine segment in order to allow for a pregnancy. If such a woman becomes pregnant, she is monitored by an obstetrician because the pregnancy is considered high risk due to the shortened cervix. Also, as a result of this procedure, these women will require a C-section section to deliver their babies.
Bilateral Salpingo-Oophorectomy (BSO)
BSO is surgery that removes both fallopian tubes and ovaries. It is typically done at the same time as the hysterectomy, but not always. Sometimes, if a hysterectomy is done for benign reasons, the ovaries may be left behind; however, if an endometrial or uterine cancer is identified in the final pathology, a second surgery may be required to remove the tubes and ovaries to reduce the risk of recurrence.
Unilateral Salpingo-Oophorectomy (USO)
USO is surgery that removes one fallopian tube and one ovary.
A vaginectomy is a surgical procedure that removes part or all of the vagina.
Simple Vulvectomy / Wide Local Excision
This procedure involves the removal of the tumour, ensuring that clear tissue is removed with it. Often this means removing the skin and some of the fat tissue underneath. Typically this removes one side or the other of the vulva. This is reserved for precancerous or benign tumors.
Modified Radical Vulvectomy with Lymphadenectomy
This surgery involves removal of more tissue than the Simple Radical Vulvectomy and wide local excision. Usually, the vulva (labia majora/minora), along with a clear margin of healthy tissue, is removed. Depending on the location of the tumour, this surgery involves taking a sampling of one or both sides of the lymph nodes in the groin.
Some centres use sentinel lymph node mapping to follow the drainage of the vulvar tumour in order to sample those specific lymph nodes for possibility of spread. This involves the injection of a radionucleotide, and sometimes a blue tracer dye, into the tumour on the vulva the morning of your surgery. During the surgery, the surgeon uses a probe to find the lymph nodes that drain the area and removes them for pathology analysis. This minimizes the number of lymph nodes that are removed during the surgery, decreasing potential long-term side effects of leg swelling.
A pelvic exenteration is a major operation used only in very specific circumstances. It may involve many different surgeons. There are 3 different types of exenteration; anterior, posterior and total.
An anterior exenteration involves the removal of the uterus, cervix, tubes, ovaries, bladder and sometimes the front wall of the vagina. A neo (new) bladder is created either as a pouch that requires catheterization, or with an external appliance or bag (ileo conduit) to collect urine.
A posterior exenteration involves the removal of the uterus, cervix, tubes, ovaries, rectum and back part of the vagina. A colostomy will be created for bowel movements.
A total exenteration involves removing the uterus, cervix, tubes, ovaries, bladder, rectum and vagina. This means that two ostomies are brought up to the skin. A colostomy will be created for bowel movements and a pouch or bag (conduit) for urine collection. Sometimes a neo (new) vagina may be created but this requires regular vaginal dilation after surgery to maintain its shape.
These procedures are only considered in very select cases. Usually they are done if there has been a tumour recurrence that is limited to the pelvis, with no evidence of recurrence anywhere else in the body. Most patients will require a special test called a PET-CT. This scan looks at the entire body to see if there are any traces of activity that might indicate cancer in other areas of the body such as liver and lungs. If the PET-CT is clear, then an exenteration might be done in order to clear the body of the tumour in the pelvis and produce clear margins.
Sometimes an exenteration may be indicated for palliative reasons, such as to control bleeding if alternative options are not effective or available. Recovery from any one of these procedures is quite lengthy and requires a prolonged hospital stay and intensive recovery.
Other Treatment Options
Chemotherapy or “chemo” is the use of specialized drugs that are known to target cancer cells anywhere in the body. This is known as systemic chemotherapy as it travels through the blood stream to all parts of the body. In the process of undergoing chemotherapy, normal healthy cells are also damaged. The cells most at risk of seeing the effects of chemotherapy are blood cells, such as red blood cells that carry oxygen, white blood cells that help ward off infection, and platelets that help to heal a cut. Other cells that may be affected are those that grow quickly. These include the lining of your mouth and digestive tract, your nails and hair, and sometimes your skin.
Chemotherapy works on cancer cells by stopping their ability to divide and grow.
Chemotherapy is used to slow the growth and spread of cancer cells that may not have been able to be removed withsurgery, or it can be used to help shrink the size of an established tumour.
Most chemotherapy drugs used to treat cancer are given intravenously; however, ongoing research is underway. Different ways of giving chemotherapy are being developed; in fact, some chemotherapy is given in pill form.
Intravenous (IV) Chemotherapy
IV chemotherapy injects the drugs directly into the blood stream to allow it to circulate throughout the body.
IV chemotherapy is given in cycles. The treatment is given, followed by days to weeks off before the next treatment is due. Your doctor will explain to you the best way to give you chemotherapy depending on your situation. This may include one or more drugs, over several cycles. Many types of chemotherapy involve 3-6 cycles.
Intraperitoneal (IP) Chemotherapy
Intraperitoneal chemotherapy is the delivery of chemotherapy directly into the abdominal cavity through a specialized port that is placed in your belly. This is given in addition to standard IV chemotherapy.
IP chemotherapy is given in cycles. The treatment is given, followed by a few weeks off before the next treatment is due.
IP chemotherapy is indicated in select cases only. Speak with your physician to see if you are considered to be a candidate for this treatment.
The development of new drugs and treatment techniques requires that clinical trials be done in order to compare results of new therapies to those that are already in use. Sometimes this involves new drugs that show promise as part of treatment for your specific cancer, or it may involve new surgical or radiation techniques. You may be approached to participate in clinical trials at some point during your treatment. Participation in clinical trials is completely voluntary and, should you decide not to participate in one, does not affect your care.
However, some are time-sensitive and may not be available in the future should you change your mind.
Radiation therapy or radiotherapy uses high energy waves to target cancer cells in a specific area to help stop them from growing. Radiation is only available at specialized cancer centres, and sometimes this may require you to travel outside of your local area for treatment.
There are two specific ways that radiation can be delivered. This may be from the outside (external beam radiation), or internally, where the radiation source is placed on or near the tumour (brachytherapy).
External Beam Radiation Therapy (EBRT)
Certain cancers may be treated with external beam radiation alone or in combination with chemotherapy.
To deliver the radiation, a large machine is used to aim the beam of radiation to a specific site where the tumour is/was and the tissues surrounding it. In order to ensure that the beam is aimed at the same site each time, small tattoos will be placed in order to help guide the beam placement for each treatment.
When the radiation is being delivered, it is much like getting an x-ray. Treatments are usually given daily, Monday to Friday, over a course of 2-7 weeks.
Brachytherapy requires a radioactive source to be placed within the vagina, cervix or vulva at or near the site of the tumour. Brachytherapy is given differently depending on the area that is being treated. When treating the upper vagina after a hysterectomy for uterine cancer, a special hollow tube is placed in the vagina that allows the radiation to be delivered directly to the site of the tumour. This does not require any sedation and is given typically once per week for 3 insertions.
In treating cervical cancer, patients are given a small amount of anaesthetic to reduce discomfort in the area during the procedure. This anaesthetic does not put you to sleep like during an operation; rather it relaxes you to allow the radiation oncologist to place the instruments in the correct spot. The treatment takes about 15 minutes to deliver, but the entire process is about an hour from start to finish. You may also require a CT (CAT scan) to ensure proper placement of the instruments. This is usually done during the first brachytherapy treatment in order to obtain measurements for the remaining treatments. You may also have an ultrasound during the procedure to check for correct instrument placement. Once the treatment is complete, the instruments are removed and you will need to recover from the anaesthesia that was used. Once you have recovered you may go home. Please ensure that you have a ride to take you home from this treatment as you will not be able to drive as a result of the anaesthetic. Most people will have 1-5 of these brachytherapy treatments.
Both these radiation treatments are done on an outpatient basis. You will not be radioactive after either of these procedures.
Your radiation oncologist will review your case and inform you of the best treatment plan that is applicable to your condition. Some patients have one or both of these radiation therapies as part of their treatment plan.
Hormones are chemical substances that the body produces in specific glands or that can be reproduced in a medical laboratory. Hormone therapy is a “systemic” type of treatment but is typically given in pill form. The purpose of hormone therapy is to counteract the effects of hormones that are naturally produced by the body. It is used to treat uterine/endometrial cancer in the following circumstances:
• After surgery to destroy any cancer cells left behind, to reduce the risk of the cancer coming back.
• As first line treatment for recurrence (when cancer has come back).
• When surgery is not possible, or fertility is a consideration.