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CERVICAL CANCER - TREATMENT
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.

Surgical Intervention

Stage IA1

Fertility is Desired

  • If patient wishes to preserve fertility, cone biopsy with negative margins is recommended if without lymphovascular space invasion
    • Depth of invasion is shown to be <3 mm
    • There are clear margins
      • If margins are positive, repeat cone biopsy to assess depth of invasion or trachelectomy is recommended
    • No vascular or lymphatic invasion is noted
    • In the absence of lymphovascular invasion, patients have a relatively low risk of lymphatic metastasis (<1%)
  • If with lymphovascular invasion, surgical option is cone biopsy with negative margins or radical trachelectomy with pelvic lymphadenectomy with or without sentinel lymph node mapping
    • If margins are positive on cone biopsy, repeat cone biopsy or trachelectomy is recommended
    • Radical trachelectomy involves removal of the cervix, vaginal margins and supporting ligaments and leaving the main body and fundus of the uterus intact
  • Since the rate of ovarian metastases is low, the ovaries may be preserved in young premenopausal patients(<45 years) 
  • Hysterectomy may be performed after completion of childbearing in patients who underwent either cone biopsy or radical hysterectomy

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 (simple) hysterectomy is recommended
    • 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 procedures are recommended:
    • Modified radical hysterectomy with pelvic lymphadenectomy with or without mapping of sentinel lymph node 
    • Pelvic EBRT with brachytherapy

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

Fertility is Desired

  • Patient may undergo radical trachelectomy plus pelvic lymphadenectomy
    • Sentinel lymph node mapping 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 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
  • The ovaries may be preserved in young premenopausal patients

Fertility Not Desired

  • Modified radical hysterectomy plus pelvic lymph node dissection is the recommended treatment
    • Sentinel lymph node mapping should be considered
    • Para-aortic lymph node dissection is recommended for patients with suspected or known pelvic nodal disease

Stage IB1, IB2 and IIA1

  • Surgical treatment is radical hysterectomy (for tumors ≤2 cm for stage IB1, IB2 and IIA1 only) and bilateral pelvic lymphadenectomy
  • Para-aortic lymphadenectomy is recommended especially in patients with larger tumors, or with suspected or known pelvic nodal disease or ≥stage IB1 cancer
    •  Sentinel lymph node mapping should be considered
  • 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
  • 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

Fertility is Desired - Stage IB1 and Select IB2

  • 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 stage IB1 and select IB2 (tumor <20 mm in diameter) with or without para-aortic lymphadenectomy
    • Sentinel lymph node mapping 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
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