What is the best treatment approach for an elderly patient with invasive cervical cancer, a short cervix, no vaginal invasion, a small uterus with dense adnexa, and a palpable lymph node, following a punch biopsy?

Treatment Approach for Elderly Patient with Invasive Cervical Cancer and Palpable Lymph Node

This elderly patient with invasive cervical cancer and a palpable lymph node should receive primary concurrent chemoradiation therapy (external beam radiation plus brachytherapy with weekly cisplatin), not surgery, as the palpable lymph node indicates at least stage IIIB disease, which mandates definitive chemoradiation as the standard of care. 1

Critical Staging Assessment Required

The palpable lymph node is the key finding that determines treatment strategy. The presence of a palpable pelvic or para-aortic lymph node automatically classifies this patient as having nodal metastasis (N1), which corresponds to at least stage IIIB disease regardless of the primary tumor characteristics. 1

Immediate Staging Workup Needed:

• PET-CT from skull base to mid-thigh is mandatory to assess the extent of nodal involvement (pelvic versus para-aortic) and exclude distant metastases, as this directly impacts radiation field design. 1
• Pelvic MRI with IV contrast should be obtained to precisely delineate local tumor extent, parametrial involvement, and vaginal extension for radiation treatment planning. 1
• The "dense adnexa" finding requires clarification—determine if this represents parametrial extension (stage IIB) or actual adnexal involvement (which would be stage IVB as distant metastasis). 1

Standard Treatment: Concurrent Chemoradiation

Surgery is contraindicated in this patient. The presence of a palpable lymph node indicates locally advanced disease (at minimum stage IIIB), and radical hysterectomy is only appropriate for early-stage disease (IA2, IB, IIA) without nodal involvement. 1

Definitive Chemoradiation Protocol:

• External beam pelvic radiation: 45-50 Gy to the whole pelvis, with upper border at L4-L5 junction, covering the gross disease, parametria, and at-risk nodal volumes. 2
• Concurrent weekly cisplatin: 40 mg/m² administered during external beam radiotherapy, which provides a 6% absolute improvement in 5-year survival compared to radiotherapy alone. 2
• Brachytherapy boost: Minimum of 2 applications to achieve total dose to point A of 80-90 Gy. 2
• Critical timing requirement: The entire treatment course (external beam plus brachytherapy) must be completed within 8 weeks, as prolonged duration significantly worsens local control and survival. 2

Extended-Field Radiation Considerations:

• If para-aortic nodes are involved (confirmed by PET-CT or surgical staging), extended-field radiation to the para-aortic region is mandatory as standard treatment. 1, 2
• If only pelvic nodes are involved, prophylactic para-aortic radiation remains controversial with unproven benefit and increased toxicity risk. 1

Age-Specific Considerations for Elderly Patients

Age alone should not preclude standard chemoradiation therapy. Studies demonstrate that cervical cancer has the same prognosis in elderly versus younger women, and age is not an independent risk factor for death. 3

Treatment Modifications for Elderly Patients:

• Carboplatin can substitute for cisplatin if the patient is cisplatin-intolerant due to renal insufficiency or other comorbidities common in elderly patients. 2
• Performance status and comorbidities (not chronologic age) should guide treatment intensity decisions. 3
• Radiotherapy alone (without concurrent chemotherapy) is acceptable for elderly patients with poor performance status who cannot tolerate chemotherapy, though survival outcomes are inferior. 1, 3

Critical Pitfalls to Avoid

• Do not perform radical hysterectomy in this patient—the palpable lymph node indicates nodal disease, and surgery in this setting leads to increased morbidity from combined modality therapy without survival benefit. 1, 4
• Do not omit brachytherapy—it is an essential component providing the high-dose boost to central disease that cannot be replaced by external beam alone. 2
• Do not exceed 8 weeks total treatment duration—treatment prolongation beyond 8 weeks is associated with significantly worse local control and survival outcomes. 2
• Do not assume the palpable node is benign—in the context of invasive cervical cancer, a palpable lymph node must be considered metastatic until proven otherwise. 1

Alternative Surgical Staging Option

Surgical lymph node assessment (extraperitoneal or laparoscopic) before initiating chemoradiation is an option to definitively determine para-aortic nodal status, which would mandate extended-field radiation if positive. 2, 5 However, this is optional (Category 2B evidence) and most centers rely on PET-CT imaging for nodal assessment. 1, 2

Prognosis and Follow-Up

Elderly patients with cervical cancer treated with radiotherapy demonstrate local control rates of 88.5% and overall survival of 73.1%, comparable to younger patients. 3 The palpable lymph node significantly worsens prognosis compared to node-negative disease, but concurrent chemoradiation remains the best chance for cure. 2