Management depends on the stage of disease.
Pre-malignant changes
Carcinoma in situ
Microinvasive Disease (IA)
Early Stage, Non-Bulky (IB/IIA, < 4 cm)
Surgery or radiotherapy are equally effective but surgery alone is associated with a better side effect profile and is typically preferred. Radiotherapy (external beam 45 Gy + brachytherapy boost 24 Gy/3#) is an alternative for patients who refuse surgery.
Adjuvant radiotherapy is indicated as per a GOG randomised trial when there is a combination of 'lesser' risk factors on histopathology:
- Lymphovascular invasion and tumour extension into the outer third of the cervical stroma
- Lymphovascular invasion and a 3 cm tumour involving the middle third of the cervical stroma
- Lymphovascular invasion and a 5 cm tumour involving the inner third of the cervical stroma (very rare presentation)
- No lymphovascular invasion but a 4 cm tumour involving the middle or outer third of the stroma
This seems quite difficult to remember!
- Always give RT if the outer third is involved unless there is no LVI and the tumour is < 4 cm
- Only give RT for inner third involvement if the tumour is large AND has LVI
- Large tumours (4 cm+) should get RT unless they are only involving the inner third of the stroma
Recurrence is 30% without treatment and 15% with RT (45 Gy in 25#)
Adjuvant chemoradiotherapy is given when the patient should have had chemoRT anyway:
- Positive nodes
- Parametrial extension (stage IIB)
- Positive margins
Recurrence is 50% without treatment, 30% with RT alone and 20% with chemoRT (50.4 Gy in 28#)
Early Stage, Bulky (IB-IIA, > 4 cm)
Locally Advanced (IIB, III, IVA)
This group of tumours is non-operable. It includes patients with parametrical extension of tumour (T2b/Stage IIB), invasion into the lower third of the vagina (T3a/Stage IIIA), invasion of local structures (T4/Stage IVA), and those with nodal metastases (Stage IIIB). Primary treatment is chemoradiotherapy (as per RTOG 90-01 and confirmed in later meta-analysis). Surgery can be used for recurrent disease.
Most treatments include:
- External beam radiotherapy with concurrent chemotherapy (cisplatin)
- Fields include the para-aortic nodes if they have not been resected and are macroscopically enlarged
- Chemotherapy is sufficient for microscopically involved nodes
- Brachytherapy boost using tandem and ovoids
For an in depth discussion of brachytherapy technique, see the Radiotherapy topic.
