Copyright Docent överläkare Dep of OB&G Skane univ hosp Lund … · 2017. 6. 28. · Recurrence...

Lund

Cervixcancer

Vad är aktuellt ?

Jan Persson Docent överläkare

Dep of OB&G Skane univ hosp Lund Sweden

Copyright Jan Persson

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


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



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



Problems with the use of SLN techiques

for cervical and endometrial cancer

No standardization

Injection sites

Doses

Volumes

Types of tracers

Timing



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?


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


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 !!!



Cervical cancer

Radikal hysterektomi

Pelvic LND

Nerve sparing techniques

PS

Symp



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.



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



Distance from the

cerclage to the cervical

inner os Jan Persson SFOG 2014


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


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



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



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


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


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



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



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………



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 !


http://www.practicumroboticschool.org/

Thank You for Your attention

[email protected]!


Copyright Docent överläkare Dep of OB&G Skane univ hosp Lund … · 2017. 6. 28. · Recurrence...

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