Combination chemotherapy may consist of vincristine, doxorubicin, and cyclophosphamide (VAC)or VP-16 (etoposide) and cisplatin (EP) (56). Patients must be monitored carefully because they are at high risk for developing recurrent metastatic disease (57).
Table 36.3 Incidence of Pelvic and Para-aortic Lymph Node Metastasis by Stage aReferences 74, 103, 110, 113, 114, 156. bReferences 14, 74, 76, 86, 87, 90–94, 157. cReferences 14, 15, 87, 90, 91, 95, 123.
Patterns of Spread Cancer of the cervix spreads by (i) direct invasion into the cervical stroma, corpus, vagina, and parametrium; (ii) lymphatic metastasis; (iii) blood-borne metastasis; and (iv) intraperitoneal implantation. The incidence of pelvic and para-aortic nodal metastasis is shown in Table 36.3.
The cervix is commonly involved in cancer of the endometrium and vagina. The latter is rare, and most lesions that involve the cervix and vagina are designated cervical primaries.
Consequently, the clinical classification is that of cervical neoplasia extending to the vagina, rather than vice versa. Endometrial cancer may extend into the cervix by three modes: direct extension from the endometrium, submucosal involvement by lymph vascular extension, and multifocal disease. The latter is most unusual, but occasionally a focus of adenocarcinoma may be seen in the cervix, separate from the endometrium. This lesion should not be diagnosed as metastasis but rather as multifocal disease. Malignancies involving the peritoneal cavity (e.g., ovarian cancer) may be found in the cul-de-sac and extend directly into the vagina and cervix. Carcinomas of the urinary bladder and colon occasionally extend into the cervix. Cervical involvement by lymphoma, leukemia, and carcinoma of the breast, stomach, and kidney is usually part of the systemic pattern of spread for these malignancies. Isolated metastasis to the cervix in such cases may be the first sign of a primary tumor elsewhere in the body.
Treatment Options The treatment of cervical cancer is similar to the treatment of any other type of malignancy in that both the primary lesion and potential sites of spread should be evaluated and treated. The therapeutic modalities for achieving this goal include primary treatment with surgery, radiotherapy, chemotherapy, or chemoradiation. Whereas radiation therapy can be used in all stages of disease, surgery is limited to patients with stage I to IIa disease. The 5-year survival rate for stage I cancer of the cervix is approximately 85% with either radiation therapy or radical hysterectomy. A study using the National Cancer Institute’s Surveillance Epidemiology and End Results data by an intent-to-treat analysis showed that patients in the surgery arm had an improved survival when compared with patients in the radiation arm (58). Optimal therapy consists of radiation, or surgery alone, to limit the increased morbidity that occurs when the two treatment modalities are combined. Recent improvements in the treatment of cervical carcinoma include adjuvant chemoradiation in patients discovered to have high-risk cervical carcinoma after radical hysterectomy and in patients with locally advanced cervical carcinoma.
Table 36.4 Management of Invasive Cancer of the Cervix
LVSI, lymphovascular space invasion.