Cervical%20cancer%20-%20treatment Diagnosis

Blood Tests

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

Diagnostic 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

Additional Tests

• Cystoscopy and proctoscopy under anesthesia should be reserved for patients with disease stage IB3 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, to rule out diseases that are high in the endocervical area and to assist in radiation treatment planning
• 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
    • PET/CT is recommended for ≥stage IB2 to assess for nodal or extrapelvic tumor
  • 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

• 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	IA	T1a
Stromal invasion ≤3 mm in depth	IA1	T1a1
Stromal invasion >3 mm and ≤5 mm	IA2	T1a2
Invasive carcinoma with deepest invasion >5 mm (>stage IA); lesion is confined to the cervix with size measured by maximum tumor diameter2	IB	T1b
Invasive carcinoma with deepest invasion >5 mm and ≤2 cm in greatest dimension	IB1	T1b1
Invasive carcinoma with deepest invasion >2 cm and ≤4 cm in greatest dimension	IB2	T1b2
Invasive carcinoma >4 cm in greatest dimension	IB3
Cervical carcinoma invades beyond the uterus but not to pelvic wall or to lower 3rd of vagina	II	T2
- Without parametrial invasion	IIA	T2a
- Invasive carcinoma ≤4 cm in greatest dimension	IIA1	T2a1
- Invasive carcinoma >4 cm in greatest dimension	IIA2	T2a2
- With parametrial invasion but no extension to pelvic sidewall	IIB	T2b
Carcinoma extends to pelvic wall and/or involves lower 3rd of vagina and/or causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes	III	T3
Carcinoma involves lower 3rd of vagina with no extension to pelvic wall	IIIA	T3a
Carcinoma extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney	IIIB	T3b
Invades pelvic and/or para-aortic lymph nodes including micrometastases3 irrespective of tumor size and extent and with r and p notations4	IIIC
- Pelvic lymph node metastasis only	IIIC1
- Para-aortic lymph node metastasis	IIIC2	N1
Carcinoma extends beyond the true pelvis or invades bladder or rectal mucosa. The presence of bullous edema is not sufficient to classify a tumor as stage IV	IV	T4
Adjacent pelvic organs spread present	IVA	T4
Presence of distant metastasis	IVB	M1

¹Sources: Bhatla N, Berek JS, Fredes MC, et al. Revised FIGO staging for carcinoma of the cervix uteri. Int J Gynaecol Obstet. 2019 Apr;145(1):129-135 and National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: cervical cancer version 1.2021. NCCN.https://www.nccn.org/. 02 Oct 2020.
²Involvement of lymphatic or vascular spaces will not change the staging and lateral extent of the lesion is no longer considered.
³Isolated tumor cells do not change the stage but presence should be recorded.
⁴Notation of r (imaging) and p (pathology) is added to indicate the results which are used to allocate the case to stage IIIC.