What is the further management for a 54-year-old female with Stage 1A2 infiltrating squamous cell carcinoma of the cervix with 3-5 mm invasion after undergoing abdominal hysterectomy with bilateral salpingo-oophorectomy (BSO)?

Management of Stage IA2 Squamous Cell Carcinoma of Cervix After Hysterectomy

For a 54-year-old female with Stage IA2 infiltrating squamous cell carcinoma of cervix with 3-5 mm invasion who has already undergone abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymphadenectomy is required as the next step in management.

Rationale for Pelvic Lymphadenectomy

According to the ESMO Clinical Recommendations, Stage IA2 cervical cancer requires pelvic lymphadenectomy as standard management 1. This is because:

• Stage IA2 disease (3-5 mm invasion) carries a higher risk of lymph node metastasis compared to Stage IA1
• The risk of lymph node metastasis in lesions with depths of invasion up to 3 mm is less than 1%, but increases significantly with deeper levels of invasion 2
• Pelvic lymphadenectomy is essential for accurate staging and determining the need for adjuvant therapy

Management Algorithm

1. Immediate next step: Pelvic lymphadenectomy

   • This is required for proper staging and risk assessment 1
   • Para-aortic lymph node sampling may also be considered but is optional 1

2. Based on lymph node status:

   • If lymph nodes are negative:

     • Observation is typically recommended 1
     • Consider pelvic radiation with or without vaginal brachytherapy if other high-risk factors are present (lymphovascular space invasion, poor differentiation) 1

   • If lymph nodes are positive:

     • Adjuvant concurrent chemoradiation with cisplatin-based chemotherapy is recommended 1
     • This significantly reduces risk of recurrence and improves survival

Follow-up Protocol

After completion of treatment, the patient should be followed with:

• Clinical and gynecological examinations every 3 months for the first 2 years 1, 3
• Every 6 months for the next 3 years 3
• Yearly thereafter 3
• PAP smears should be included in these follow-up visits 1, 3

Important Considerations

• Lymphovascular space invasion (LVSI) is an important prognostic factor that increases risk of recurrence and should be evaluated in the pathology specimen 1, 4
• The risk of pelvic lymph node metastasis in Stage IA2 disease is approximately 1-8% 5, 6
• While the patient has already undergone hysterectomy, it's important to verify whether it was an extrafascial or radical hysterectomy, as this may influence further management decisions 1

Potential Pitfalls

1. Skipping lymphadenectomy: The most common error is to assume that hysterectomy alone is sufficient treatment for Stage IA2 disease. Without lymph node assessment, occult metastases may be missed.

2. Overtreatment: Not all patients with Stage IA2 disease require adjuvant radiation. This should be reserved for those with positive nodes or other high-risk features.

3. Inadequate follow-up: Given the potential for recurrence, adherence to the recommended surveillance schedule is critical for early detection of recurrent disease.