Post on 20-Feb-2021
Lund
Cervixcancer
Vad är aktuellt ?
Jan Persson Docent överläkare
Dep of OB&G Skane univ hosp Lund Sweden
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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”
Jan Persson SFOG 2014
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Our patient selection for surgery of cervical cancer Stage 1a2 to 1b12 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
Jan Persson SFOG 2014
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Sentinel node technique Nervesparing technique Fertility sparing surgery Economy Survival and recurrence pattern
Jan Persson SFOG 2014
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Problems with the use of SLN techiques
for cervical and endometrial cancer
No standardization
Injection sites
Doses
Volumes
Types of tracers
Timing
Jan Persson SFOG 2014
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Jan Persson Riyadh/ London / Barcelona
How is a sentinel lymph node defined?
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?
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Physics behind it….
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 Jan Persson SFOG 2014
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Issues of importance
How is a sentinel lymph node defined?
-The first/ closest to cervix if more than one….. on each side
The obvious ones !!!
Jan Persson SFOG 2014
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Cervical cancer
Radikal hysterektomi
Pelvic LND
Nerve sparing techniques
PS
Symp
Jan Persson SFOG 2014
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Gynecol Oncol. 2012 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.
Jan Persson SFOG 2014
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http://www.ncbi.nlm.nih.gov/pubmed/22935472http://www.ncbi.nlm.nih.gov/pubmed?term=Persson%20J%5BAuthor%5D&cauthor=true&cauthor_uid=22935472http://www.ncbi.nlm.nih.gov/pubmed?term=Imboden%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22935472http://www.ncbi.nlm.nih.gov/pubmed?term=Reynisson%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22935472http://www.ncbi.nlm.nih.gov/pubmed?term=Andersson%20B%5BAuthor%5D&cauthor=true&cauthor_uid=22935472http://www.ncbi.nlm.nih.gov/pubmed?term=Borgfeldt%20C%5BAuthor%5D&cauthor=true&cauthor_uid=22935472http://www.ncbi.nlm.nih.gov/pubmed?term=Bossmar%20T%5BAuthor%5D&cauthor=true&cauthor_uid=22935472
Robotic radical trachelectomy
Time for surgery
Vaginal radical trachelectomy
Time for surgery
Circles= conversion to a
Radical hysterectomy
Jan Persson SFOG 2014
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Distance from the
cerclage to the cervical
inner os Jan Persson SFOG 2014
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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 Jan Persson SFOG 2014
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0
1000
2000
3000
4000
5000
6000
7000
8000
0 100 200 300 400 500 600
€/OP
Fixed cost
Robot specific costs (EURO)
Fixed cost = based on 7 year depreciation including annual maintenance
Robot instruments - robot draping cost per operation
Nfnnf
nnfn
Fixed cost and instruments costs shall be added
Annual number of operations
Jan Persson SFOG 2014
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OR minute charge = 17€ (167SEK) 2 hours use of OR equals robot cost
Inpatient day charge = 400€ (400=SEK) 4.8 days equals robot cost
Economy on robotic radical hysterectomy in Lund
Jan Persson SFOG 2014
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ROBOT-ASSISTED LAPAROSCOPIC RADICAL HYSTERECTOMY AND PELVIC LYMPHADENECTOMY : A HOSPITAL COST ANALYSIS.
Objective. To compare robot-assisted laparoscopy and laparotomy for radical hysterectomy and pelvic lymphadenectomy in terms of hospital costs
Pétur Reynisson MD, Jan Persson MD PhD Associate professor
Department of Obstetrics and Gynecology, Skåne University Hospital, Lund, Sweden.
0 30 60 90 120 150 180
0
1
2
3
4
5
6
7
8
Open Robot1-30
Robot31-60
Robot61-90
Robot 91-120
Robot121-150
Robot151-180
Days
readmissionInitial stay
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
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.
€/unit Open
Robot
1-30
Robot
31-60
Robot
61-90
Robot
91-120
Robot
121-150
Robot
151-180
OR time (minutes)* 18.7 299 406 334 323 288 260 277
Post operative stay (days)* 395 7.3 5.5 3.6 3.8 3.5 3.3 2.4
Admittance fee * 476 1.1 1.2 1.0 1.2 1.2 1.2 1.1
Erythrocyte concentrate* 109 1.0 0.2 0.2 0.0 0.1 0.1 0.0
Laparotomy-associated cost* 222 1.1 0.1 0.0 0.1 0.1 0.1 0.1
Robot-associated cost* *
661 0 1 1 1 1 1 1
Robot investment cost* * *
604 0 1 1 1 1 1 1
Robot maintenance cost 289 0 1 1 1 1 1 1
Robotic instruments 277 0 4.61 4.20 3.97 3.83 3.40 3.40
Total cost (€) 9339 13221 10913 10780 10014 9290 9176
p- value
* * * *
5Y survival
5Y disease free
survival
% pos pelvic nodes
% pos paraaort nodes
Overall 70%
Stage Ia 95-100% 94-100% rare -
Stage IB1 90.5% 65-90%
17%
5-10%
Stage IB2 79.5%
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%
5 year survival of cervical cancer according to FIGO clinical stages
Source; FIGO, Shingleton/orr Cancerof the cervix Jan Persson SFOG 2014
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FIGO
Stage n= Node
pos
Radiatio
n
Recurrenc
e Total 1 Year 2 Years
3
Years
4
Years
5
Years
Local 0 0% 0% 0% 0% 0% IA2 27 1 1 Distal 0 0% 0% 0% 0% 0%
4% 4% DID 0 0% 0% 0% 0% 0% n= 27 22 19 14 12
Local 7 2% 4% 7% 9% 9%
IB1* 12
3 31 53 Distal 10 6% 8% 10% 9% 9% 25% 43% DID 8 2% 6% 8% 7% 9%
*23 under staged n= 123 109 96 82 58
Local 0 0% 0% 0% 0% 0% IB2 7 4 5 Distal 1 14% 17% 25% 0% 0%
57% 71% DID 1 0% 17% 25% 0% 0% n= 7 6 4 3 1
Local 1 0% 10% 10% 13% 13% 2A 11 3 7 Distal 1 9% 10% 10% 13% 13%
27% 64% DID 1 0% 0% 0% 13% 13% n= 11 10 10 8 8
168 39 66 168 147 129 107 79
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Recurrence pattern for node neg cx-ca patients without adjuvant treatment following RRH n=100
Recurrence ≤12 months
Recurrence 12-23 months
Recurrence ≥24months
Median time to recurrence
32 months (range 3-39)
Recurrence rate 7%
Of those 1 of 7 (14%) DID
Lung
Lung & supraclav
Rec FIGO n= DID
IA2 26 7 IB1 69 1
IB2 2 2A 3
7 Total 100 1
Jan Persson SFOG 2014
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Recurrence pattern for cx-ca patients with adjuvant treatment following RRH n=68
Recurrence ≤12 months
Recurrence 12-23 months
Recurrence ≥24months
Median time to recurrence
10 months (range 5-25)
Recurrence rate 19%
9 of 13 (69%) DID
Lungs
Port
Paraaort
Supraclav
Recur Lnn+ FIGO n= Lnn+ DID Lnn+
0 0 IA2 1 1 0 0 10 7 IB1 54 31 7 5 1 1 IB2 5 4 1 1 2 1 2A 8 3 1 0
13 69% Total 68 57% 9 67%
Inguinal
Jan Persson SFOG 2014
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Conclusion RRH for early stage cervical cancer
• 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………
Jan Persson SFOG 2014
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Thank you for your attention!
Welcome to Lund for training and a complete overview
of applications of robot assisted surgery in gynecology
www.practicumroboticschool.org
NEXT Masterclass Oct 20 - 24
2014 !
Copyright Jan Persson
http://www.practicumroboticschool.org/
Thank You for Your attention
jan.persson@med.lu.se!
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