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5.3 Invasive - Squamous Cell Carcinoma & Adenocarcinoma

5.3.1 Stage IA 

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 BC Cancer and that the patient is presented to the multidisciplinary conference for a treatment recommendation.

a. Stage IA1 without LVI
If margins are negative, conservative treatment with simple hysterectomy is recommended. If margins are positive, simple or modified radical hysterectomy with sentinel lymph node biopsy +/- pelvic lymph node dissection is recommended. Occasionally, for very early disease removed with a satisfactory margin, cold knife conization or LEEP may be considered adequate therapy, if fertility preservation is an issue.

b. Stage IA1 with LVI and stage IA2
Radical treatment will be required. This will usually be surgical, including modified radical hysterectomy with pelvic lymph node dissection (or sentinel lymph node biopsy). If fertility preservation is desired, radical trachelectomy with pelvic lymph node dissection (or sentinel lymph node biopsy) could be considered. If the patient is not a surgical candidate, then radical radiotherapy would be used with a combination of external beam treatment plus intracavitary/interstitial brachytherapy.

Role of Sentinel Lymph Node Biopsy for Stage IA1 with LVSI to IB1
Sentinel lymph node mapping can increase the detection of metastatic lymph nodes over conventional lymphadenectomy, as mapping studies have shown that up to 10% of sentinel nodes are found in areas not captured in a standard pelvic lymph node dissection. In addition, diagnostic accuracy is increased with the use of pathological ultrastaging for the sentinel node. 

Appropriate candidates for sentinel lymph node biopsies in lieu of pelvic lymphadenectomy include patients who meet all of the following criteria:
  • Tumor diameter less than 4cm
  • No suspicious lymph nodes seen on pre-operative imaging or during surgery
  • Bilateral sentinel lymph node detected intra operatively
If a sentinel lymph node is not identified intraoperatively, a full pelvic lymph node dissection should be performed in that hemipelvis. Patients who do not meet the above mentioned criteria for sentinel lymph node biopsy should have a full bilateral pelvic lymphadnectomy.  

When used appropriately, the sensitivity of a sentinel node biopsy has been reported to be 99.6% with a negative predictive value of 99.9%. 

References

  1. Tax C, Rovers MM, de Graaf C, Zusterzeel PL, Bekkers RL. The sentinel node procedure in early stage cervical cancer, taking the next step; a diagnostic review. Gynecol Oncol. 2015;139(3):559-67

Adjuvant Radiotherapy
Adjuvant pelvic radiotherapy is recommended when simple hysterectomy is inadvertently performed where modified radical hysterectomy and pelvic lymph node dissection (or sentinel lymph node biopsy) was needed for treatment of the invasive disease. Completion of radical hysterectomy is not routinely recommended but can be discussed in multidisciplinary rounds.

Postoperative radiotherapy will also be recommended following radical hysterectomy in the face of poor prognostic factors (see below).

5.3.2 Stage IB1 and IIA1

We recommend either radical surgery or primary radiochemotherapy.

Radical surgery may be considered as primary therapy in the following situations: 
  • Absence of a highly aggressive histology 
  • Contraindications to primary radiation therapy 
  • Suitable surgical and anesthetic risk 
Patients not fulfilling these criteria will be treated with primary radiotherapy.

Adjuvant Radiotherapy
Adjuvant pelvic radiotherapy is recommended if 2 or more of the following features exist:
  • LVI 
  • Deep stromal invasion
  • Tumor ≥4 cm
Adjuvant Concurrent Radiochemotherapy
Adjuvant pelvic radiotherapy +/- vaginal vault brachytherapy with concurrent chemotherapy is recommended if any of the following is identified on pathology: 
  • Positive pelvic lymph node
  • Positive parametrial involvement
  • Positive margin

5.3.3 Stage IB2, IIA2, IIB, III or IV

Concurrent radiochemotherapy with pelvic external beam radiation treatment followed by intracavitary +/-interstitial brachytherapy is recommended (see radiotherapy section below). If there is evidence of residual disease at 3 months after completion of radiotherapy, salvage hysterectomy may be considered. These cases should be presented at multidisciplinary conference.

Radiotherapy can be used for palliation and local-regional control in the metastatic setting. Palliative chemotherapy can be considered (see below).


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