Stage Ia1 and Ia2 Cancer

The treatment of these lesions will be based on a thorough histologic examination of a properly obtained cone biopsy specimen. It is strongly recommended that all these patients have their slides reviewed at the BC Cancer Agency and that the patient be presented to the Gyne Disposition group for a treatment recommendation.

Patients presenting with Stage Ia microinvasive carcinoma with 3 mm or less of invasion without lymphatic vascular space involvement, conservative treatment with simple hysterectomy will be recommended. Occasionally, for very early disease removed with a satisfactory margin, conization may be considered adequate therapy, if fertility preservation is an issue.

If invasion is 3 mm or less and lymphatic vascular space invasion is present, treatment recommendation will be made after slide review and may vary from conservative to radical therapy.

In the case of adenocarcinoma, the need for further treatment will be individualized depending upon the extent of the disease. Therapy will be tailored accordingly and will range from cone biopsy only to radical hysterectomy with lymph node dissection.

In the case of patients with lesions exceeding 3 mm in depth, Stage Ia2, radical treatment will be required. This will usually be surgical, including treatment of the nodes. If the patient is not a surgical candidate, then radical radiotherapy would be used with a combination of external beam treatment plus intracavitary therapy.

When simple hysterectomy is inadvertently performed in the face of invasive carcinoma, post operative radiotherapy will be recommended. Post operative radiotherapy will also be recommended following radical hysterectomy in the face of poor prognostic factors

Stage Ib and IIa

The treatment of patients with Stage Ib and IIa tumours is highly individualized depending on various specific histologic and clinical findings. Patients with tumour diameter <4 cm will be treated with either radical surgery or primary radiotherapy. Radiotherapy usually involves intracavitary insertions as well as external beam radiation treatment.

Radical hysterectomy and pelvic lymphadenectomy may be considered as primary therapy in the following situations: 

1. Depth of invasion more than 3 mm
2. Lesion less than 4 cm in diameter
3. Absence of a highly aggressive histology
4. absence of extensive lymphovascular invasion
5. Contraindications to primary radiation therapy such as TB, syphilis, PID not responding to conservative therapy with antibiotics, large uterine fibroids or undiagnosed adnexal masses
6. Suitable surgical and anesthetic risk

Patients not fulfilling this criteria will be treated with primary radiotherapy.

In the case of patients treated surgically and in whom the pathologic specimen review reveals metastatic tumour within lymph nodes or positive surgical margins, lymphatic invasion, or a deeply invasive lesion, external beam therapy to the pelvis will usually be recommended after discussion at the gyne disposition meeting.

Stage II, III or IV

Lesions will be managed with external radiation treatment delivered to the pelvic region. Following external radiation treatment the patients undergo pelvic examination and, if the disease has regressed centrally, the treatment is completed with two intracavitary cesium insertions one week apart. However, if significant parametrial or side wall disease persists, instead of intracavitary treatment, further external beam boost treatment is delivered . If disease persists after radiotherapy further surgery may be considered.

Adenocarcinoma

Adenocarcinomas of the cervix are treated in the same manner as the more common squamous carcinomas.

Small Cell Carcinoma

This is an uncommon variant of cervical carcinoma which, like lung small cell, is usually systemic in spread and has a much worse 5 year survival. All patients need urgent chemotherapy +/- radiotherapy to the pelvis and para-aortic regions to try to improve both local and systemic control. Definitive surgery is not recommended, and urgent referral is advised.