Treatment/Prognosis

Question 1

What is the most important prognostic factor in cervical cancer?

Answer 1

Tumor stage is the most important prognostic factor in cervical cancer since FIGO staging is based on prognostic factors. Per stage, extent of nodal involvement is the next most important factor.

Question 2

What is removed in a radical trachelectomy as Tx for cervical cancer?

Answer 2

In a radical trachelectomy, all cervical cancer is removed with a margin, but the internal os is left behind and stitched closed, with a small meatus for menses to escape. This procedure allows future pregnancy, delivered via a C-section. This procedure should be reserved for women desiring fertility preservation and with stage IA1 as well as select cases of IA2 and small IB1 and tumors

Question 3

How should pts with preinvasive cervical cancer (HGSIL or CIN III) be managed?

Answer 3

Pts with preinvasive cervical cancer should be managed with colposcopy → conization, LEEP, laser, cryotherapy, or simple hysterectomy.

Question 4

In which subset of cervical cancer pts is simple hysterectomy adequate as definitive management?

Answer 4

Pts with IA1 Dz can be treated with simple abdominal hysterectomy. A cone should be done 1st to ensure that there are no foci of invasion beyond 3 mm identified. Sometimes, conization is also adequate for IA1, but there must be DOI < 3 mm and no LVSI or dysplasia at the margin. (Van Nagell J et al., Am J Obstet Gynecol 1983) All other pts (≥ IA2) should get radical hysterectomy with pelvic LND.

Question 5

What is the difference between a class II and class III radical hysterectomy (Piver-Rutledge-Smith classification)?

Answer 5

• In a class II modified radical hysterectomy (Piver-Rutledge-Smith classification), there is removal of the uterus, ureters are unroofed to remove parametrial and paracervical tissue medial to the ureters and 1– 2 cm of vaginal cuff, and the uterine artery is ligated at the ureter.
• In a class III surgery, there is removal of parametrial and paravaginal tissue to the pelvic sidewall, ligation of the uterine artery at the ureter, and removal of the upper half to two-thirds of the vagina.

Question 6

What stage of cervical cancer can be treated with brachytherapy alone?

Answer 6

Stage IA cervical cancer can be treated with brachytherapy alone with LDR 65– 75 Gy or HDR 7 Gy × 5– 6 fx, with LC of 97%. (Grisby P et al., IJROBP 1992)

Question 7

When treating cervical cancer pts with brachytherapy, is there a Dz control or toxicity difference between LDR and HDR?

Answer 7

• This is uncertain.
• In Teshima T et al., pts with stages I– III cervical cancer were randomized to HDR cobalt-60 or LDR cesium-137 therapy.
• There was no SS difference in 5-yr CSS between the 2 groups (stage I, 85%– 93%; stage II, 73%– 78%; stage III, 47%– 53%).
• Moderate to severe complications were higher in HDR (10% vs. 4%). (Cancer 1993)