Radical trachelectomy should be restricted to candidates with low-risk disease and a tumor size less than 2 cm. The para-aortic lymph node chain must be evaluated, especially if pelvic nodal disease is encountered. Adjuvant radiation therapy is recommended if intermediate risk factors are identified postoperatively. Adjuvant chemoradiation is indicated if high risk features are found.
Alternatively, primary chemoradiation therapy with curative intent is appropriate. A comparison of radical hysterectomy with radiation resulted in similar survival rates for the two treatment modalities. Several studies comparing patients treated by either radical hysterectomy or radiation therapy showed similar survival rates and outcomes for both groups (85,157). However, patients treated with type III radical hysterectomy who subsequently received postoperative radiation had a higher rate of intestinal and urinary morbidity compared with patients treated with either modality alone. Therefore, some clinicians advocate using radiation and avoiding surgery in these patients because many will require adjuvant postoperative radiation.
Bulky Stages IB2 and IIA2 Invasive Cancer Patients with bulky IB2 and IIA2 disease may be treated with either primary chemoradiation or radical surgery. Because many of these patients will have intermediate or high risk factors postoperatively, strong consideration should be given to primary chemoradiation. If surgical therapy is desired, a type III radical hysterectomy with pelvic and para-aortic lymphadenectomy, followed by adjuvant chemoradiation if intermediate or high risk factors are present, is appropriate therapy. This option has benefits of complete surgical staging and ovarian preservation, if desired. Disadvantages of primary surgery include increased morbidity if multimodality therapy is utilized (157).
Stages IIB to IIIB Invasive Cancer Therapy for patients with stage IIB or greater cervical cancer traditionally was radiation therapy. Primary pelvic radiotherapy fails to control disease progression in 30% to 82% of patients with advanced cervical carcinoma (3). Two-thirds of these failures occur in the pelvis (158). A variety of agents were used in an attempt to increase the effectiveness of radiation therapy in patients with large primary tumors. Because chemoradiation was superior to radiation therapy alone, chemoradiation is the preferred treatment strategy for these patients, with cisplatin the chemotherapy agent of choice. Nodal involvement, particularly the para-aortic lymph nodes, is the most important factor related to survival (see section above on Concurrent Chemoradiation).
Stages IVA and IVB Cancer Primary exenteration may be considered for patients with direct extension to the rectum or bladder, but it is rarely performed. For patients with extension to the bladder, the survival rate with radiation therapy is as high as 30%, with a urinary fistula rate of only 3.8% (159). The presence of tumor in the bladder may prohibit cure with radiation therapy alone; thus, consideration must be given to removal of the bladder on completion of external beam radiation treatment. This is particularly true if the disease persists at that time and the geometry is not conducive to brachytherapy. Rectal extension is less commonly observed but may require diversion of the fecal stream before chemoradiation to avoid septic episodes from fecal contamination. In certain clinical situations, such as with patients who have stage IVA disease and present with vesicovaginal or rectovaginal fistula, urinary or rectal diversion may be performed, followed by chemoradiation.
Patients with stage IVB cervical carcinoma are candidates for chemotherapy and palliative pelvic radiation therapy. Control of symptoms with the least morbidity is of primary concern in this patient population.