What are the staging and treatment options for a patient with cervical cancer (cervical carcinoma)?

Cervical Cancer Staging and Treatment

FIGO Staging System

The International Federation of Gynecology and Obstetrics (FIGO) staging system is the standard classification for cervical cancer, with staging based on clinical examination supplemented by imaging findings and lymph node status. 1, 2

Diagnostic Workup for Staging

• MRI is superior to CT scan for tumor extension assessment and should be the preferred imaging modality for pelvic and abdominal evaluation. 3, 1, 2
• Thoracic CT scan should be included for metastasis assessment. 3, 1
• PET imaging is useful for nodal assessment, particularly in advanced disease. 1, 2
• Routine laboratory tests include complete blood counts, renal and liver function tests. 3, 1
• SCC antigen may be useful for follow-up in squamous cell carcinomas if initially elevated. 3, 1
• Surgical pelvic and para-aortic lymph node staging remains optional. 3

The 2018 FIGO revision now formally incorporates cross-sectional imaging and pathological findings into staging, addressing the historical problem of understaging that occurred with clinical examination alone. 4, 5, 6

Stage-Specific Treatment Recommendations

Stage IA1 (Invasion ≤3 mm depth)

For patients without lymphovascular space invasion (LVSI), conization with negative margins or simple hysterectomy based on patient age is the standard treatment. 3, 1, 2, 7

• If LVSI is present, add pelvic lymphadenectomy to the surgical approach. 3, 1, 2, 7
• If pelvic nodes are positive, proceed with complementary concurrent chemoradiation. 3, 1

Stage IA2 (Invasion >3 mm but ≤5 mm)

Surgery is the standard treatment, with pelvic lymphadenectomy mandatory. 3, 1, 7

• Options include conization or trachelectomy for young patients desiring fertility preservation. 3, 1, 7
• Simple or radical hysterectomy for other patients. 3, 7
• If pelvic nodes are positive, add complementary concurrent chemoradiation. 3, 1

Stage IB1 (Tumor ≥5 mm and <2 cm)

Multiple equally effective treatment options exist: radical hysterectomy with pelvic lymphadenectomy, external beam radiation plus brachytherapy, or combined radio-surgery. 3, 1, 2, 7

• Conservative surgery (conization or trachelectomy) can be considered for tumors with excellent prognostic factors in young patients desiring fertility. 3, 1, 7
• If pelvic nodes are positive after surgery, add complementary concurrent chemoradiation. 3, 1

Stage IB2 (Tumor 2-4 cm) and IIA2

Concurrent chemoradiation is preferred over surgery for tumors >4 cm. 1, 7

• The standard regimen consists of weekly cisplatin 40 mg/m² during external beam radiation therapy, providing an absolute 5-year survival benefit of 8%. 1, 2, 7
• External beam radiation plus brachytherapy is an essential component. 1
• The entire course of external beam and brachytherapy must be completed within 8 weeks, as treatment duration >8 weeks is associated with worse outcomes. 1, 2

Stage IB3 (Tumor ≥4 cm), IIB-IVA

Standard treatment is concurrent chemoradiation with weekly cisplatin 40 mg/m² during external beam radiation therapy. 1, 2, 7

• Brachytherapy is an essential component of definitive treatment. 1, 2
• Total dose to target should be 80-90 Gy. 1
• Complete treatment within 8 weeks to optimize outcomes. 1, 2

Stage IVB (Distant Metastases)

Platinum-based combination chemotherapy is the standard palliative treatment. 1, 2

• For stage IV-B, recurrent, or persistent cervical cancer not amenable to curative treatment, topotecan plus cisplatin is FDA-approved. 8
• The topotecan regimen is 0.75 mg/m²/day IV over 30 minutes on days 1,2, and 3, followed by cisplatin 50 mg/m² on day 1, repeated every 21 days. 8
• Median survival with topotecan plus cisplatin was 9.4 months versus 6.5 months with cisplatin alone (HR 0.76, p=0.033). 8

Special Considerations

Fertility Preservation

For young women with stage IA1-IB1 disease desiring fertility, cone biopsy with negative margins or trachelectomy are appropriate options. 1, 7

• Ovarian preservation may be considered for premenopausal women with squamous cell carcinoma undergoing hysterectomy. 7
• Ovarian transposition should be performed before pelvic radiation in women <45 years. 7

Recurrent Disease

For locoregional recurrence in radiotherapy-naïve patients, salvage chemoradiation with curative intent is recommended. 2

• Pelvic exenteration may be considered in highly selected cases for previously irradiated patients. 2
• For distant metastatic recurrence, platinum-based combination chemotherapy is standard. 2

Follow-Up Protocol

Surveillance should occur every 3 months for the first 2 years, every 6 months for years 3-5, and yearly after 5 years. 2, 7

• Each visit should include clinical and gynecological examination with PAP smear. 2, 7
• Annual cervical/vaginal cytology and imaging as indicated. 2, 7

Critical Pitfalls to Avoid

Never exceed 8 weeks total treatment time for chemoradiation, as this significantly worsens outcomes. 1, 2

• Do not attempt curative-intent extended-field chemoradiation for patients with para-aortic lymph node involvement and distant metastases. 2
• Ensure baseline neutrophil count >1,500 cells/mm³ and platelet count >100,000 cells/mm³ before initiating topotecan-based chemotherapy. 8
• Monitor for severe bone marrow suppression with topotecan, which may require dose reduction or G-CSF support. 8