Treatment by FIGO

Question 1

Stage IA1

Answer 1

No LVSI:

simple “extrafascial” (type 1) hysterectomy or conisation.

If not surgical candidate: intracavital XRT. Repeat CKC if margins positive. instead of CKC - ?trachelectomy. If margins still positive - for type 2 rad hyst with Pelvic LND

LVSI:

pelvic LND and/or SLNB should be performed

Question 2

Stage 1A2 to IB2

Answer 2

Radical hysterectomy and bilateral salpingectomy +/- bilat oophorectomy with bilateral PLND. Piver type 1/2

but on consultation:

If 1B1 but no LVSI and negative pelvic LN - then 0.4% chance of parametrial involvement so ?T1 hyst is acceptable (within a trial)

Younger women may want to keep their ovaries

Women with stage IA2 cervical carcinoma who wish to preserve their fertility are eligible for conization/ simple or radical trachelectomy irrespective of grade and lymph-vascular space invasion, as long as clear margins can be achieved, and no pathological LN are identified in
staging.

Question 3

Stage IB1/2 and wants fertility?

Answer 3

radical trachelectomy and cerclage + bilateral pelvic lymphadenectomy and/or SLNB is an option but needs counselling by an experienced team about higher oncological risks.

May required adjuvant chemoradiotherapy if high ris

Question 4

Stage IB3 to IVA

Answer 4

Currently standard treatment is:

Chemo-radiotherapy with EBRT, BT and Cisplatin

Important to try to avoid combined surgical/medical treatment as there is a higher morbidity.

Question 5

Incidental finding of disease on hysterectomy

Answer 5

If Stage IA1 with LVSI or more:
Get imaging - if margins neg and imaging neg
1. WP EBXRT and brachytherapy with cisplatin
OR
2. parametrectomy with upper vaginectomy and P-LND +/- PA-LND

if pos margins or gross residual disease:

1. neg LN on imaging - WP EBXRT with cisplatin (brachytherapy dependent on vaginal margins)
2. pos LN on imaging - debulk gross LN then WP and PA EBXRT with cisplatin +/- brachy dependent on vaginal margins

Question 6

Fertility sparing IA2

Answer 6

Women with stage IA2 cervical carcinoma who wish to preserve their fertility are eligible for
conization/ simple or radical trachelectomy irrespective of grade and lymph-vascular space
invasion, as long as clear margins can be achieved, and no pathological LN are identified in
staging.

Question 7

How does the treatment recommendation change for adenocarcinoma

Answer 7

Young patients with adenocarcinoma should be counselled carefully regarding bilateral
salpingoophorectomy, due to the higher risk of metastases and/or relapse in the adnexa
compared to squamous cell histology (Grade A)

Question 8

What is the SHAPE trial

Answer 8

Wright et al found that patients with stage IB1 cervical cancer (FIGO 2018) with no LVSI and negative pelvic nodes had only 0.4% risk for parametrial invasion and, therefore, could have received simple hysterectomy.

A randomized phase III trial comparing radical hysterectomy and pelvic node dissection vs simple hysterectomy and pelvic node dissection in patients with low risk early stage cervical cancer less than 2cm, including those with IA1 disease.

Question 9

Which LN are removed

Answer 9

Traditionally, the removal of lymph nodes is recommended from the following anatomical regions:

external iliac lymph nodes from the bifurcation of common iliac artery to the deep circumflex iliac vein;

the nodes around the internal iliac vessels;

the nodes from the obturator fossa down to the level of the obturator nerve.

Question 10

Fertility sparing up to IB1

Answer 10

Radical trachelectomy with cerclage and bilateral pelvic lymphadenectomy and/or SLN is an option for patients with cervical cancer up to stage Ib1

Question 11

Who can have a trachelectomy

Answer 11

up to stage Ib1

Question 12

What percentage of people achieve one live birth after trachelectomy

Answer 12

50-66%

Question 13

radical hysterectomy - laparoscopy vs laparotomy

Answer 13

Recent evidence from a prospective randomized trial (311) and a large SEER meta-analysis (312) showed
a significant compromise of overall oncologic outcome in terms of both progression-free and overall
survival of the minimal invasive compared to the open approach for patients with early stage cervical
cancer up to 4cm.

In their May 2019 statement, ESGO advised that in radical hysterectomy, open approach is the gold standard.

Question 14

Who should be offered adjuvant chemoradiotherapy

Answer 14

High-risk factors:

• Positive pelvic/para-aortic lymph nodes
• Parametrial spread
• Positive surgical margins (microscopic)

Consider offer for:

Intermediate-risk factors:

• Presence of LVSI
• Tumour maximum diameter >4cm at final pathology
• Deep cervical stromal invasion (>1/3)

Question 15

What is the risk of adnexal mets
SCC 1B
vs
adeno 1B

Answer 15

0.2% SCC IB

vs

3.72% adeno IB

Question 16

When might we use frozen section at cervical cancer treatment?

Answer 16

To obtain margins at trachelectomy with a clearance of 5-10mm.

Question 17

What are the risks of conisation of the cervix

Answer 17

Cervical incompetence
Cervical stenosis
Premature delivery - can lead to NND and complications of extreme prematurity

Question 18

What do you do if there are positive CIN margins after conisation?

Answer 18

Repeat conisation.

Question 19

What if the conisation specimen cannot be orientated, is fragmented or has diathermy artefact - meaning that margins can’t be assessed?

Answer 19

Repeat conisation.

Question 20

When would you consider surgery in an advanced cervical cancer?

Answer 20

Perhaps in stage IVA for symptom control - for example you would consider pelvic exenteration if there is a fistula.

Question 21

What do you do if you have locally advanced disease but no clear LN on imaging?

Answer 21

Can consider para-aortic LND (at least up to the level of the IMA)