RAMB Novembro/Dezembro 2015

ervical

cancer

what

’

new

ssoc

ras

2015; 61(6):536-542

537

tion of the specimen and thermal artifacts, which may

hinder the histological analysis, and, therefore, in such

cases scalpel conization is preferred. If there is no inter-

est in preserving fertility, the recommendation is that the

surgery should include plain hysterectomy. Bilateral sal-

pingectomy associated with hysterectomy to prevent ovar-

ian carcinoma is also recommended. However, if there is

lymphovascular invasion (very rare situation for this depth

of invasion), radical hysterectomy (Class B according to

Morrow and Querleau

with resection of the parametri-

um at the level of ureter) and pelvic lymphadenectomy,

or sentinel lymph node technique can be indicated. If the

patient wants to preserve fertility, radical trachelectomy

can be offered.

As for IA2 and IB1 stages, for patients who do not

want to preserve fertility, the best alternative

is radical

hysterectomy class C, by Morrow and Querleau, with re-

section of parametrium at the level of internal iliac artery,

which corresponds to the classical Werteim-Meigs oper-

ation, or type III-V Piver-Rutledge, in addition to pelvic

lymphadenectomy. For these stages (IA2 and IB1), the

sentinel lymph node technique can be proposed to pre-

vent radical lymphadenectomy and risks of associated

morbidities (evidence and recommendation 2B for sen-

tinel lymph node). In these stages, if the patient has a clin-

ical contraindication or if she does not accept the surgery,

the choice becomes exclusive radiotherapy, using telether-

apy supplemented by brachytherapy. Radical surgical pro-

cedures can be performed by laparotomy or laparoscopy,

including robotic surgery.

Surgery as initial treatment is not indicated for IB2,

IIA1 and IIA2 cancers. The probability of positive mar-

gins or other indications for radiotherapy or chemother-

apy in these stages is very high, around 80%. We know

that the addition of adjuvant therapies to surgery (chemo-

radiation) increases morbidity, worsening the quality of

life of the patient.

9-11

An important component of the treatment of cervi-

cal carcinoma in the early stages is adding radiation ther-

apy in situations at high risk for local or systemic recur-

rence. Poor prognostic indicators are obtained from

surgical specimens and include the following: positive

pelvic lymph nodes, parametrial involvement or positive

surgical margin. More recently, another category of prog-

nostic indicators was added to clinical practice and ap-

plies to patients without any of the cited criteria. These,

considered as minor criteria, are: diameter of the prima-

ry tumor associated with lymphovascular invasion, or

TABLE 1

Staging of cervical cancer (Figo 2009*).

Stage

Description

In situ

carcinoma

Carcinoma strictly confined to the cervix (extension to the uterine

corpus

should be disregarded)

Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of

5mm and no wider than 7mm

IA1

Measured invasion of stroma ≤3mm in depth and ≤7mm width

IA2

Measured invasion of stroma >3mm and ≤5mm in depth and ≤7mm width

Clinical lesions confined to the cervix, or preclinical lesions greater than stage IA

IB1

Tumor ≤4cm

IB2

Tumor >4cm

IIA

Involvement of up to the upper 2/3 of the vagina

IIA1

Tumor ≤4cm

IIA2

Tumor >4cm

IIB

Parametrial tumor involvement

III

The carcinoma has extended onto the pelvic sidewall and involves the lower third of the vagina and/or hydronephrosis and/

or non-functioning kidney

IIIA

Involvement of the lower vagina but no extension onto pelvic sidewall

IIIB

Extension onto the pelvic sidewall, or hydronephrosis/non-functioning kidney

The carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum (prov-

en by biopsy). Note: bullous edema is not considered stage IV.

IVA

Spread to bladder and/or rectum

IVB

Spread to distant organs

*Figo Proposals reviewed by the International Gynecologic Cancer Society during the Figo meeting in 2006. International Journal of Gynecology & Obstetrics. 2009;105 (2):103-194.