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
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