What is the treatment for cervical squamous cell carcinoma?

Treatment of Cervical Squamous Cell Carcinoma

Treatment for cervical squamous cell carcinoma is determined by FIGO stage, with early-stage disease (IA-IB1) treated primarily by surgery, locally advanced disease (IB2-IVA) treated with concurrent cisplatin-based chemoradiation, and metastatic disease (IVB) treated with platinum-based combination chemotherapy. 1

Staging Requirements Before Treatment

Before initiating treatment, complete staging must include:

• Clinical gynecological examination 1
• MRI is superior to CT for tumor extension assessment and should be preferred for pelvic and abdominal imaging 1
• Blood counts and chemistry including renal and liver function 1
• Thoracic CT for metastasis assessment 1
• SCC antigen levels (useful for follow-up if initially elevated) 1

A multidisciplinary treatment team must establish the treatment plan in all cases. 1

Treatment by FIGO Stage

Stage IA1 (Microinvasive, ≤3mm depth, ≤7mm width)

Standard treatment is conization with free margins or simple hysterectomy based on patient age and fertility desires. 1

• If lymphovascular space involvement (LVSI) is present: add pelvic lymphadenectomy 1
• If pelvic nodes are positive: proceed to concurrent chemoradiation 1

Stage IA2 (Microinvasive, >3mm but ≤5mm depth)

Surgery is the standard approach with mandatory pelvic lymphadenectomy. 1

Options include:

• Conization or trachelectomy for young patients desiring fertility preservation 1
• Simple or radical hysterectomy for other patients 1
• If pelvic nodes are positive: add concurrent chemoradiation 1

Stage IB1 (Confined to cervix, ≤4cm)

Multiple treatment options exist with equivalent outcomes: surgery alone, external beam radiation plus brachytherapy, or combined radio-surgery. 1

Surgical approach:

• Radical hysterectomy with pelvic lymphadenectomy 1
• Bilateral oophorectomy is optional 1
• Conservative surgery (trachelectomy) can be offered for tumors with excellent prognostic factors in young patients 1

If surgical pathology reveals pelvic node involvement, parametrial extension, <3mm uninvolved cervical stroma, or positive margins: add concurrent chemoradiation. 1

Stages IB2, IIA2, IIB-IVA (Locally Advanced Disease)

Concurrent cisplatin-based chemoradiation is the standard treatment of choice based on five randomized trials showing survival benefit. 1

Standard regimen:

• Cisplatin 40mg/m² weekly during external beam radiation 1
• External beam pelvic radiation: 45-50.4 Gy 1
• Followed by intracavitary brachytherapy to boost point A to approximately 80-85 Gy 1

Alternative concurrent regimens for cisplatin-intolerant patients:

• Carboplatin-based chemoradiation 1
• Cisplatin plus 5-fluorouracil (though more toxic) 1

For premenopausal women <45 years with squamous cell histology, consider ovarian transposition before pelvic radiation to preserve hormonal function. 1

Stage IVB (Distant Metastatic Disease)

Platinum-based combination chemotherapy is the standard palliative treatment. 1

The addition of bevacizumab to platinum-based chemotherapy improves survival in recurrent, persistent, or metastatic disease. 2

Recurrent Disease Management

Isolated Pelvic Recurrence

For localized recurrence confined to the cervix or adjacent tissues, pelvic exenteration surgery offers the best chance for long-term survival (29% 5-year survival with salvage surgery vs 3% without). 3

Salvage surgery is most successful when:

• Tumor is confined to the cervix (22% 5-year survival) 3
• Tumor extends to adjacent tissues but remains within pelvis (9% 5-year survival) 3
• Early detection of recurrence occurs 3

Isolated Para-aortic Lymph Node Recurrence

Aggressive treatment with extended-field chemoradiation can achieve 27% 5-year survival for isolated para-aortic nodal recurrence. 3

This represents a potentially curable scenario that warrants aggressive salvage treatment. 3

Distant Metastatic Recurrence

Palliative platinum-based combination chemotherapy is the standard option for most patients with distant metastases. 1

Critical Treatment Principles

Avoid combined modality therapy (surgery followed by radiation) when possible, as it increases complication rates without improving survival compared to either modality alone. 1

Patients with persistent disease after initial treatment have similar outcomes to those with relapse after complete remission, so both groups warrant aggressive salvage attempts. 3

Nutritional status must be optimized and maintained throughout treatment, as this impacts tolerance and outcomes. 4, 5

Follow-up Protocol

After treatment completion:

• Clinical gynecological examination with Pap smear every 3 months for 2 years 1
• Every 6 months for years 3-5 1
• Annually thereafter 1
• Imaging (CT/MRI) as clinically indicated for suspected recurrence 1
• Note that radiation causes cellular changes that can complicate cytological interpretation 6