Cancer of the cervical stump was more common many decades ago when supracervical hysterectomy was popular; because this operation is being performed more frequently, this situation may become increasingly familiar. Early-stage disease is treated surgically, with very little change in technique from that used when the uterus is intact (172). Radical parametrectomy with upper vaginectomy and pelvic lymphadenectomy is the standard procedure. Advanced-stage disease may present a therapeutic problem for the radiotherapist if the length of the cervical canal is less than 2 cm. This length is necessary to allow satisfactory placement of the uterine tandem. If the uterine tandem cannot be placed, radiation therapy can be completed with vaginal ovoids or with an external treatment plan in which lateral ports are used to augment the standard anterior and posterior ports. Such a technique will reduce the dosage to the bowel and bladder and thus reduce the incidence of complications.
Pelvic Mass The origin of a pelvic mass must be clarified before treatment is initiated. A CT urogram can exclude a pelvic kidney, and a barium enema helps to identify diverticular disease or carcinoma of the colon. An abdominal x-ray film may show calcifications typically associated with benign ovarian teratomas or uterine leiomyomas. Pelvic ultrasonography differentiates between solid and cystic masses and indicates uterine or adnexal origin. Solid masses of uterine origin are most often leiomyomas and do not need further investigation.
An enlarged ﬂuid-filled uterine cavity may be a pyometra or a hematometra. The hematometra can be drained by dilation of the cervical canal and will not interfere with treatment. The pyometra also should be drained, and the patient should be given antibiotics to cover bacteroides species, anaerobic staphylococcus and streptococcus species, and aerobic coliform bacterial infection. Placement of a large mushroom catheter through the cervix was advocated, but the catheter itself may become obstructed, leading to further occlusion of the drainage. Repeated dilation of the cervix with aspiration of pus every 2 to 3 days is more effective.
If the disease is stage I, a radical hysterectomy and pelvic lymphadenectomy may be performed. However, a pyometra is usually found in patients with advanced disease, and thus radiotherapy is required. External-beam therapy can begin after the pyometra is healed. Patients often have a significant amount of pus in the uterus or a tubo-ovarian abscess without signs of infection; therefore, a normal temperature and a normal white blood cell count do not necessarily exclude infection. Repeat physical examination or pelvic ultrasonography is necessary to ensure adequate drainage.
When invasive cervical cancer is found after simple hysterectomy, further treatment is predicated on the extent of disease. Microinvasive disease in patients at low risk for lymph node metastasis does not require further treatment. Invasive disease may be treated with radiotherapy or reoperation involving a pelvic lymphadenectomy and radical excision of parametrial tissue, cardinal ligaments, and the vaginal stump (173).
Reoperation Reoperation is indicated for a young patient who has a small lesion and in whom preservation of ovarian function is desirable. It is not indicated for patients who have positive margins or obvious residual disease (173). Survival rates after radical reoperation are similar to those after radical hysterectomy for stage I disease.
Concurrent cisplatin-based chemoradiation is recommended for gross residual disease, positive imaging, disease in the lymph nodes or parametrium, or a positive surgical margin; individualized brachytherapy is clearly indicated for a positive vaginal margin (174).