Cervical%20cancer%20-%20treatment Diagnosis

• 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.

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

• 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