Useful Links: National Cancer Institute (Staging)
Currently used International Federation of Gynaecology and Obstetrics system of aging (FIGO staging) is based on anatomical extent of the disease and on clinical evaluation. When there is doubt as to which stage a particular cancer should be allocated, the earlier stage is mandatory.
Detection/Staging
In patients with histologically (biopsy, endo-cervical curettage and/or cone biopsy) confirmed cervical carcinoma, a staging procedure is required that involves colposcopy, vaginal and rectal examination, cystoscopy and recto-sigmoidoscopy, to assess the extension to the surrounding structures (parametria, baldder and rectum). Suspected bladder and/or rectal involvement should be confirmed histologically.
Computed tomography (CT) scanning and magnetic resonance imaging (MRI) are usually preformed to determine lymphadenopay and parametrial spread, respectively.
To rule out small nodal disease, particularly in para-aortic region where external radiation may offer a survival advance, Positron emission tomography (PET) scanning is the preferred approach. PET was shwon to be significanly superior to CT/MRI (sensitivity: 92% vs. 60%) in identifying metastatic lesions.
Treatment of Cervical Cancer by Stages:
–Stage Ia microinvasive disease:
Interest in defining this sub-stage of cervical cancer is motivated by the desire to preserve fertility and prevent the potential complications of radical treatment.
–Stage Ia1 cervical cancer: defined as minimal microscopic invasion (depth <3mm, width <7mm) can be managed conservatively. Treatment options are –conization, in women wishing to retain their reproductive potential, assuming complete excision of the lesion, –simple hysterectomy, in women who do not wish to retain fertility.
Some believe that presence of lymphovascular invasion requires radical treatment.
–Stage Ia2 cervical cancer: depth 3-5 mm, with <7mm have the risk of nodal disease of about 7% and accordingly, unless there are strong reasons for conservative treatment, the patient can be treated by primary radical hysterectomy, modified radical hysterectomy with pelvic lymphadnectomy or primary radiotheraphy.
–Stage Ib-IIa cervical cancer:there is no standard treatment. Most patients are treated by either radical surgery or radical radiotheraphy. Combinations of surgery and radiotherpahy are also used.
–stage Ib1 and early stage IIa disease: radical hysterectomny with pelvic lymphadnectomy (pelvic lymph nodes are carefully dissected to remove as many of the nodes as possible)
–Stage Ib2 disease: treatment of bulky stage Ib tumors (primary tumors greater than 4 cm) is difficult and whatever primary treatment is chose, the recurrence rate is higher when compared to stage Ib1 disease. While some centers are performing primary surgery as for stage Ib1 disease followed by tailored postoperative radiation with or without chemotheraphy, others are in favor of pirmary radiation therapy.
The rate of pelvic relase is significantly higher among patients with stage Ib2 disease who had radiation alone (30%) compared to those who had surgery plus adjuvant radiation (20%).
Neoadjuvant ehmotheraphy is a possible alternative in treatment. The rational is that apart form eradicating micrometastases, it would debulk the tumor and thus improve the outcome of subsequent surgery or radiotherpahy.
-Stage IIB-IVa cervical cancer: radiotheraphy has long played a mjaor role in the treatment of locally advance cervical cancer. Standard treatment for advanced cervical cancer is radical external beam radiation theraphy plus brachytheraphy. It is important that appropirate dosing is administered to the central tumor and the pelvic side wall nodes.
There is strong evidence that chemotheraphy should be incorporated into radiation treatment of patients with advanced cervical caner. Today, concurrent cisplatin-based chemo-radiation is considered the treatment of choice in locally advanced, metastatic and recurrent cervical cancer. The addition of chemotheraphy has significantly improved cumulative rates of survival at 8 eyars (67% vs. 41%)