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.

Surgical Intervention

Hysterectomy

  • If without lymphovascular space invasion and margins are negative on cone biopsy, extrafascial hysterectomy is recommended for stage IA1 in whom fertility is not an issue
    • In the absence of lymphovascular invasion, patients have a relatively low risk of pelvic nodal spread (<1%)
    • If margins are positive, consider repeating cone biopsy or perform extrafascial or modified radical hysterectomy with pelvic lymph node dissection
  • Another option if there is lymphovascular invasion is modified radical hysterectomy with pelvic lymph node dissection with or without sampling of para-aortic lymph nodes
  • Extrafascial hysterectomy alone or following chemotherapy may be performed in basic-resource settings in women with stage IA1 to IVA cervical cancer in whom radiotherapy cannot be given
  • Patients with incidental finding of invasive cervical cancer after hysterectomy may be followed up without further treatment
  • Oophorectomy is optional and should be deferred in premenopausal women
  • Surgical treatment is radical hysterectomy, for tumors ≤2 cm for stage IB1 only, and bilateral pelvic lymph node dissection or lymphadenectomy
  • Para-aortic node sampling is recommended especially in patients with larger tumors, or with suspected or known pelvic nodal disease
  • Some recommend that pelvic lymph node dissection should be done initially; if the result is negative, then proceed with radical hysterectomy
    • If the result is positive, chemoradiation therapy should be started and hysterectomy should be deferred
  • Laparoscopic-vaginal radical hysterectomy is an effective and safe alternative to radical hysterectomy
    • Should not be offered in patients with >2-cm tumor diameter
  • Stage IA2-IIA patients with incidental finding of cervical cancer after hysterectomy should be considered for surgery (complete parametrectomy and pelvic lymphadenopathy) or adjuvant treatment with radiotherapy and concurrent chemotherapy

Stage IA2

  • As there is definite potential for lymph node metastasis in these patients, pelvic lymph node dissection is required in the treatment protocol
    • In the past, surgery with lymphadenectomy was needed for evaluation of lymph node metastases; however currently, alternatives for evaluation of lymph node metastases include dissection of lymph node, imaging procedures, or both

If Fertility is Desired

  • Patient may undergo radical trachelectomy plus pelvic lymphadenectomy
    • Para-aortic lymph node sampling should be considered especially in patients with suspected or known pelvic nodal disease
  • Radical trachelectomy has low morbidity, recurrence and mortality rates
  • Another option is cold knife conization or large loop excision of the transformation zone plus pelvic lymph node dissection, or large cone biopsy plus extra-peritoneal or laparoscopic pelvic lymphadenectomy
    • Cone biopsy may be performed in basic-resource settings and cone biopsy with pelvic lymphadenectomy in limited-resource settings 
    • If margins are positive, repeat cone biopsy; if margins are still positive, treat as stage IB
  • The ovaries may be preserved in young premenopausal patients

Fertility Not Desired

  • Modified radical hysterectomy plus pelvic lymph node dissection is the recommended treatment
    • Para-aortic lymph node sampling should be considered

Stage IB1

If Fertility is Desired

  • Patients who are candidates for fertility-sparing surgery are the following:
    • With largest diameter of tumor <20 mm
    • Without lymphovascular space involvement
    • Without lymph node involvement
  • Patient may undergo radical trachelectomy plus pelvic lymphadenectomy for macroscopic stage IB1 (tumor <20 mm)
    • Para-aortic lymph node sampling should be considered
    • In a study among women after radical trachelectomy for early stage cancer, the 5-year cumulative pregnancy rate was 52.8%, with low cancer recurrence rate but with higher miscarriage rate
  • Since the rate of ovarian metastases is low, the ovaries may be preserved in young premenopausal patients
  • Another option is cold knife conization or large loop excision of the transformation zone plus pelvic lymph node dissection for microscopic stage IB1
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
DOWNLOAD
Editor's Recommendations
Most Read Articles
09 Dec 2017
Intravenous (IV) iron is less toxic and more effective compared to oral iron, making it a potential frontline therapy for neonatal iron deficiency anaemia, suggests a recent study.
Shilpa Kolhe, MBBS, MD, MRCOG; Shilpa Deb, MBBS, DGO, MRCOG, 01 Aug 2012

Dysmenorrhoea is a medical condition characterized by severe uterine pain during menstruation manifesting as cyclical lower abdominal or pelvic pain, which may also radiate to the back and thighs. The term dysmenorrhoea is derived from the Greek words ‘dys’ meaning difficult, painful or abnormal, ‘meno’ meaning month, and ‘rrhea’ meaning flow. It is commonly divided into primary dysmenorrhoea, where there is no coexistent pathology, and secondary dysmenorrhoea where there is an identifiable pathological condition known to contribute to painful menstruation. Symptoms of primary dysmenorrhoea begin a few hours before the start of menstruation and are often relieved during the first few days of bleeding. The initial onset of primary dysmenorrhoea is usually shortly after menarche (6–12 months), when ovulatory cycles are established. Secondary dysmenorrhoea can also occur at any time after menarche but is most commonly observed in women in their third and fourth decade of life in association with an existing condition.

02 Dec 2014
Adolescent females often experience menstrual problems, and these are usually related to mood changes. In this study, the association between dysmenorrhea and depressive symptoms, anxiety, and premenstrual syndrome was examined.
26 Feb 2017
Placement of cervical pessary in women with short cervices and singleton pregnancies does not lower the risk of having preterm births, according to the results of a meta-analysis.