than radiation, because of vaginal shortening, fibrosis, and atrophy of the epithelium associated with radiation. Surgical therapy shortens the vagina, but gradual lengthening can be brought about by sexual activity. The epithelium does not become atrophic because it responds either to endogenous estrogen or to exogenous estrogens if the patient is postmenopausal.
Radical hysterectomy is reserved for women who are in good physical condition. Advanced chronologic age should not be a deterrent. With improvements in anesthesia, elderly patients withstand radical surgery almost as well as their younger counterparts (60). It is prudent not to operate on lesions that are larger than 4 cm in diameter because these patients will require postoperative radiation therapy. When selected in this manner, the urinary fistula rate is less than 2%, and the operative mortality rate is less than 1% (61,62). A summary of the management of cervical cancer is presented in Table 36.4.
If radiation therapy is needed, transposing the ovaries out of the planned radiation field may preserve ovarian function. Although transposition provides some protection, studies suggest that normal ovarian function is preserved in fewer than 50% of patients (63,64). Metastasis to the ovaries occurs in 0.9% of cases of early stage cervical cancer, so preservation of the ovaries, particularly with adenocarcinoma, may confer a small recurrence risk (65).
Cone Biopsy of the Cervix Cone biopsy of the cervix serves both a diagnostic and therapeutic role in cervical cancer. The procedure is indicated to confirm the diagnosis of cancer, and to definitively treat stage Ia1 disease when preservation of fertility is desired. For effective treatment, there must be no evidence of lymph–vascular space invasion, and both endocervical margins and curettage findings must be negative for cancer or dysplasia. Because stage Ia1 cancers have less than a 1% risk of lymph node metastasis, lymphadenectomy is not necessary. If the endocervical margin or curettage is positive for dysplasia or malignancy, further treatment is necessary because these findings are strong predictors of residual disease. For squamous cell carcinoma, the risk of residual disease is 4% if both the endocervical margin and curettage are negative for dysplasia or malignancy, 22% if the endocervical margin alone is positive, and 33% if both are positive (66). In cases of AIS, the status of the cone margins is particularly important, with residual preinvasive and invasive disease noted in up to 25% and 3%, respectively, of cases with negative margins, and up to 80% and 7%, respectively, in cases with positive margins (67,68).
Simple (Extrafascial) Type I hysterectomy is an appropriate therapy for patients with stage Ia1 tumors without Hysterectomy lymph–vascular space invasion who are not desirous of future fertility. In such cases,
Figure 36.6 Abdominal radical trachelectomy.
lymphadenectomy is not recommended. If lymph–vascular space invasion is found, a modified radical hysterectomy with pelvic lymphadenectomy is appropriate and effective therapy.