cervical%20cancer%20-%20treatment
CERVICAL CANCER - TREATMENT
Patients w/ abnormal Pap smear are referred for colonoscopy to screen for presence of cervical cancer.
Colposcopic exam should include inspection of the transformation zone, definition of the extent of the lesion & biopsy of the most abnormal area for tissue diagnosis.
The earliest stages of cervical carcinoma are generally asymptomatic.
Watery vaginal discharge & postcoital bleeding or intermittent spotting may be present & are usually unrecognized by the patient.

Staging

  • Cervical cancer is clinically staged, although surgical staging is more accurate
  • Staging is for comparison purposes only and not as a treatment guide

  • Clinical Findings FIGO Stages TNM Stages
    Cervical carcinoma confined to cervix (extension to uterine corpus should be disregarded) I T1
    Invasive carcinoma diagnosed only by microscopy, with deepest invasion of ≤5 mm and largest extension of ≤7 mm IA T1a
    Stromal invasion ≤3 mm in depth and horizontal spread ≤7 mm IA1 T1a1
    Stromal invasion >3 mm and ≤5 mm with a horizontal spread ≤7 mm IA2 T1a2
    Clinically visible lesion confined to the cervix or preclinical cancers >stage IA2/T1a2 IB T1b
    Clinically visible lesion ≤4 cm in greatest dimension IB1 T1b1
    Clinically visible lesion >4 cm in greatest dimension IB2 T1b2
    Tumor invades beyond the uterus but not to pelvic wall or to lower 3rd of vagina II T2

    - Without parametrial invasion

    IIA T2a

    Clinically visible lesion ≤4 cm in greatest dimension

    IIA1 T2a1

    Clinically visible lesion >4 cm in greatest dimension

    IIA2 T2a2

    - With parametrial invasion

    IIB T2b
    Tumor extends to pelvic wall and/or involves lower 3rd of vagina and/or causes hydronephrosis or non-functioning kidney3 III T3
    Tumor involves lower 3rd of vagina with no extension to pelvic wall IIIA T3a
    Tumor extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney IIIB T3b
    Regional lymph node metastasis N1
    Tumor extends beyond the true pelvis and/or invades bladder or rectal mucosa. The presence of bullous edema is not suffi cient to classify a tumor as stage T4 IVA T4
    Presence of distant metastasis IVB M1

1Sources: Pecorelli S for the FIGO Committee on Gynecologic Oncology. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105:103-104 and the American Joint Committee on Cancer (AJCC) TNM Staging System
2All macroscopically visible lesions, even with superficial invasion, are allotted to stage IB. Invasion is limited to stromal invasion with max depth of 5 mm and largest extension of ≤7 mm. The depth of invasion should not be >5 mm taken from the base of the epithelium, either surface or glandular, from which it originates. Depth of invasion should be reported in mm, including cases with “early/minimal stromal invasion” (~1 mm)
3On rectal exam, there is no cancer-free space between the tumor and pelvic wall. All cases with hydronephrosis or non-functioning kidney are included, unless they are known to be due to another cause.

Laboratory Tests

Colposcopy

  • Colposcopic exam should include inspection of the transformation zone, definition of the extent of the lesion and biopsy of the most abnormal area for tissue diagnosis
  • If possible, histological confirmation of the colposcopic diagnosis should be made before treatment
  • Diagnosis of microinvasive cervical cancer should be made based on histological exam and removal of tissue
  • Cone biopsy or conization is recommended if the cervical biopsy is inadequate to define invasiveness or if definitive assessment of microinvasive disease is required
    • Loop electrosurgical excision procedure (LEEP) is acceptable provided sufficient margins and proper orientation are achieved

Blood Tests

  • Complete blood count (CBC) with platelet count
  • Liver function tests (LFTs)
  • Renal function tests

Additional Tests

  • Cystoscopy and proctoscopy under anesthesia should be reserved for patients with disease stage IB2 or higher
    • Should be performed in patients in whom there is suspicion of bladder or rectal extension
  • Intravenous pyelogram (IVP)
  • Cone biopsy, endocervical curettage or smear
  • Other techniques (eg laparoscopic staging and robotic hysterectomy) may be used both for staging and therapeutic purposes
    • Long-term outcome data are not yet available
    • Less invasive procedures

Imaging

  • Used to guide treatment planning
  • Magnetic resonance imaging (MRI) is considered the reference complementary exam
    • Superior to computed tomography (CT) in determining tumor extension such as soft tissue and parametrial involvement, and equal to CT for nodal involvement evaluation
    • Used to evaluate extent of local disease and to rule out diseases that are high in the endocervical area
  • Chest X-ray, Bone scan, CT scan, combined positron emission tomography (PET)-CT scan
    • Combined PET-CT scan may be used to rule out extrapelvic disease, detect persistent disease or recurrences which may respond to curative salvage therapy
    • Metastatic disease may be assessed using a whole body PET/CT or a CT scan of the chest, abdomen or pelvis
  • PET is used to define the nodal volume of coverage, especially in patients who are not surgically staged
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