Treatment:
Treatment for cervical cancer depends on the stage of the disease.
A. In patients who do not want to preserve fertility, from stage IA1 where LVSI is positive to some well-selected patients in stages IB3 and IIA1 will be candidates for radical hysterectomy. The standard approach for radical hysterectomy in cervical cancer is laparotomy, and many studies have confirmed that minimally invasive procedures, both conventional laparoscopy and robotic, are associated with an increased recurrence and mortality rate. The new classification of radical hysterectomy types is based on the Querleu and Morrow system. The types of radical hysterectomy include type A, type B1, type B2, type C1, type C2, and type D. In type C1, which is a radical hysterectomy with nerve preservation, the inferior hypogastric plexus is preserved near the cardinal ligament.
B. In more advanced stages, chemoradiation is the primary principle of treatment.
C. Some patients after surgery may also need adjuvant treatments based on pathological findings. Some criteria are associated with a moderate risk of recurrence and these patients should undergo radiotherapy after surgery. These criteria are known as Sedlis criteria:
1. LVSI plus deep one-third cervical stromal invasion and tumor of any size
2. LVSI plus middle one-third stromal invasion and tumor size >2 cm
3. LVSI plus superficial one-third stromal invasion and tumor size >5 cm
4. No LVSI but deep or middle one-third stromal invasion and tumor size >4 cm
Some patients are also at high risk for recurrence after surgery and should receive adjuvant chemoradiation if there are Peters criteria:
– Positive surgical margins
– Pathologically confirmed involvement of the pelvic lymph nodes
– Involvement of the parametrium
D. Neoadjuvant chemotherapy is one of the options in cervical cancer patients who are pregnant and want to continue their pregnancy.
E. New treatments such as targeted therapy have been proposed in cervical cancer as well as other gynecological cancers. Different groups of drugs such as monoclonal antibodies have been used for this purpose in different clinical trials, such as: Angiogenesis inhibitors such as bevacizumab, EGFR inhibitors such as cetuximab, PARP inhibitors such as Velioarib, and immunotherapy with pembrolizumab and nivolumab.
Fertility sparing surgery in cervical cancer:
Cervical cancer often occurs between the ages of 35 and 44, and preserving fertility is very important in these patients. Fertility sparing methods can include uterine preservation and / or ovarian preservation.
Optimal candidates for preserving fertility:
– Desire to preserve fertility
– Young women (Preferably less than 40 years old)
– Histological types of squamous, adenosquamous or adenocarcinoma
– Early stages of the disease, ie IA1 up to a maximum of IB1 and some selected cases of IB2
– Tumor size ≤۲ cm
– Negative margin of at least 5 mm
– The disease is limited to the cervix
– There is no lymph node involvement
Types of fertility sparing surgical techniques include:
– Simple trachelectomy or radical vaginal trachelectomy (in a tumor less than 2 cm)
– Abdominal radical trachelectomy (in a tumor ≥ ۲ cm)
– Cone biopsy in lesions less than 1 cm
– NACT in lesions larger than 2 cm + a suitable fertility sparing procedure
– Ovarian preservation (even in adenocarcinoma, the risk of ovarian metastasis in the early stages is less than 5%, and ovarian preservation in these individuals does not affect the overall or disease-free survival).
If you choose conization, it is better to use cold knife conization. Although the use of LEEP is acceptable. Be sure to perform endocervical curettage with these methods.
In stage IA1, which is associated with LVSI and more advanced stages, pelvic lymphadenectomy should be performed. Sentinel lymph node mapping can be used in lesions up to 2 cm in size. The probability of parameter involvement in lesions less than 2 cm is less than one percent, and currently fertility preserving methods tend to be more conservative. MIS trachelectomy (conventional laparoscopic trachelectomy or robot-assisted trachelectomy) had similar recurrence and survival rates in compare to abdominal approaches. Avoiding the use of a uterine manipulator and performing transvaginal closure of the vaginal cuff can reduce the risk of tumor spillage during MIS.
After childbearing is complete, hysterectomy can be considered for these patients:
– Chronic persistent HPV infection
– Abnormal pap test
– Patient’s desire to surgery
Sentinel lymph node mapping: This method is part of the surgical staging of cervical cancer. The cervix is in the center of the pelvis and has bilateral lymphatic drainage, and the use of SLN mapping is practical. It is possible to inject blue dye with or without Tc99, but ICG is used if the infrared camera is available.
The injection can be done at different hours of the cervix at 2 or 4 points, such as: injection at 2, 11, 5, 7, or 3 and 9, or at 3, 6, 9, and 12. Two injections are performed at each point, one injection with a depth of 2 to 3 mm and the second injection with a depth of 1 cm. The most common areas in SLN are mapping of the lymphatic chain to the inner surface of the external iliac and the upper part of the obturator space.
The following conditions are necessary to achieve reliable results and proper mapping:
– Tumors less than 4 cm (although the best results are obtained in tumors less than 2 cm).
– There are no suspicious lymph nodes in the preoperative imaging
– bilateral SLN detection
– Ultrastaging sentinel lymph nodes
– The surgeon adheres to the SLN algorithm
Surveillance after treatment:
The goal of follow-up after treatment is to identify cancer recurrence early, which could potentially be curable. The main component of survival is clinical examination. Patients should be educated about the symptoms of relapse. lifestyle modification, exercise, smoking cessation, and nutritional improvement are also important. Cervical cytology is performed annually in patients who have used fertility preservation methods. PET / CT and other imaging modalities performed if clinically indicated.
Dr. Soheila Aminimoghaddam
Gynecology Oncologist
School of medicine
Iran University of Medical Sciences, Tehran, Iran
Email address: Aminimoghaddam.s@iums.ac.ir
