Cervical%20cancer%20-%20treatment Treatment

Stage IA1

Fertility is Desired

• If with negative lymphovascular space invasion and cone biopsy with ≥1-mm negative margin, close observation or surveillance may be done      
  • In the absence of lymphovascular invasion, patients have a relatively low risk of lymphatic metastasis (<1%)
  • If margins are positive, repeat cone biopsy to assess depth of invasion or trachelectomy is recommended
• If with lymphovascular invasion and if margins are positive on cone biopsy, repeat cone biopsy or trachelectomy is recommended
• Since the rate of ovarian metastases is low, the ovaries may be preserved in young premenopausal patients(<50 years) 

Fertility Not Desired

• If patient is medically inoperable and without lymphovascular space invasion and margins are negative on cone biopsy, observation is recommended 
• If patient is medically and technically operable and without lymphovascular space invasion and margins are negative on cone biopsy, extrafascial hysterectomy can be done     
  • If margins are positive for dysplasia or carcinoma, consider repeating cone biopsy or perform extrafascial or modified radical hysterectomy with pelvic lymphadenectomy and mapping of sentinel lymph node may be performed
• If with lymphovascular invasion, the following treatment options are recommended:
  • Modified radical hysterectomy with pelvic lymphadenectomy with or without mapping of sentinel lymph node 
  • Pelvic EBRT with brachytherapy
• If without lymphovascular space invasion and with positive margins, repeat cold knife conization or loop electrosurgical excision procedure (LEEP) is recommended

Stage IA2

• As there is definite potential for lymph node metastasis in these patients, pelvic lymph node dissection is required in the treatment protocol  

Fertility is Desired

• Patients meeting all criteria for conservative surgery (no lymphovascular space invasion, negative cone margins, any grade squamous cell carcinoma or grade 1-2 adenocarcinoma, ≤2 cm tumor size, ≤10 mm depth of invasion, and with negative imaging for metastatic disease) are recommended for cone biopsy (if with negative margins) with pelvic lymphadenectomy or sentinel lymph node mapping
• Patient may undergo radical trachelectomy, which has low morbidity, recurrence and mortality rates, plus pelvic lymphadenectomy
  • Sentinel lymph node mapping should be considered especially in patients with suspected or known pelvic nodal disease
• Another option is cold knife conization or large loop excision of the transformation zone plus pelvic lymphadenectomy, 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 or trachelectomy may be performed; if margins are still positive, treat as stage IB
  • Sentinel lymph node mapping should be considered

Fertility Not Desired

• Radical hysterectomy plus pelvic lymph node dissection is the recommended treatment
  • Sentinel lymph node mapping should be considered
  • Para-aortic lymph node dissection is also recommended
• Extrafascial hysterectomy with pelvic lymphadenectomy or sentinel lymph node mapping is recommended for patients meeting all criteria for conservative surgery

Stage IB1, IB2 and IIA1

• Surgical treatment is radical hysterectomy (for stage IB1 not meeting criteria for conservative surgery, IB2 and IIA1 only) and bilateral pelvic lymphadenectomy
• Para-aortic lymphadenectomy is recommended especially in patients with larger tumors or ≥stage IB1 cancer
  •  Sentinel lymph node mapping can be considered
• If there are positive lymph nodes on pelvic lymphadenectomy, radical hysterectomy is deferred and patient is referred for chemoradiation therapy     
• Vaginal radical hysterectomy can be an alternative to radical abdominal hysterectomy
  • Preferred treatment for FIGO stage IA2, IB1, and select IIA1 lesions when fertility preservation is not desired
  • Should not be offered in patients with >2-cm tumor diameter
• Extrafascial hysterectomy with pelvic lymphadenectomy or sentinel lymph node mapping is recommended for patients with stage IB1 tumors and meeting all criteria for conservative surgery

Fertility is Desired - Select Stage IB1 and Select Stage IB2

• Patients who are candidates for fertility-sparing surgery are the following:
  
  • With largest diameter of tumor ≤2 cm
  • Without lymphovascular space involvement
  • Without lymph node involvement
• Patients with stage IB1 tumors and meeting all criteria for conservative surgery are recommended for cone biopsy with pelvic lymphadenectomy or sentinel lymph node mapping
• Patient may undergo radical vaginal trachelectomy plus pelvic lymphadenectomy for select stage IB1 (tumor <20 mm in diameter) with or without para-aortic lymphadenectomy
  • Sentinel lymph node mapping can 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
• Abdominal radical trachelectomy may be a fertility-sparing option for patients with stage IB2 tumor