Cervical Cancer: Contemporary Management K Chitrathara, Shalini Rajaram, Amita Maheshwari
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1CERVICAL CANCER: Contemporary Management2
3CERVICAL CANCER: Contemporary Management
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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This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the editors. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
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
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7CONTRIBUTORS
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11FOREWORD
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
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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.