cervical%20cancer%20-%20treatment
CERVICAL CANCER - TREATMENT
Treatment Guideline Chart
Patients with abnormal Pap smear are referred for colposcopy to screen for presence of cervical cancer.
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.
The earliest stages of cervical carcinoma are generally asymptomatic.
Watery vaginal discharge, postcoital or postmenopausal bleeding, intermittent spotting, or abdominal pain may be present and is usually unrecognized by the patient.

Cervical%20cancer%20-%20treatment Diagnosis

Laboratory Tests

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

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, 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

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 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.

Editor's Recommendations
Special Reports