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C
ervical
cancer
:
what
’
s
new
?
R
ev
A
ssoc
M
ed
B
ras
2015; 61(6):536-542
539
rently in progress with removal of the sentinel lymph
node alone, without lymphadenectomy, in cases of neg-
ative SLN. It will, therefore, be possible to verify whether
this procedure can be regarded as the gold standard.
A
dvances
in
radiotherapy
for
cervical
cancer
With regard to radiotherapy, the novelty is the planning
of external radiation therapy (teletherapy) and brachy-
therapy guided by magnetic resonance imaging (MRI).
For study of the cervix and pelvis, as a whole, MRI showed
image resolution better than computed tomography (CT),
with better definition of anatomical planes. Thus, a bet-
ter definition of the fields would be possible, minimizing
side effects and improving tolerability to treatment with
lower toxicity in bone marrow, bladder and rectum. The
existing studies that adopt historical controls for com-
parison show improved local control and survival, espe-
cially in the treatment of advanced tumors (stage IIIB).
38-
42
But there are no prospective studies confirming these
results. Moreover, the application of these radiotherapy
techniques almost quadruples the time spent with each
patient, making it difficult to use in most public servic-
es, where there are patients awaiting radiotherapy for a
considerable time.
A
dvances
in
systemic
treatment
of
recurrent
cervical
cancer
With respect to chemotherapy, we now present some ad-
vances in the treatment of patients with metastatic dis-
ease and the role of antiangiogenic and immunogenic
therapies. For the treatment of recurrent cervical cancer,
various approaches can be employed depending on the
previous treatment, and where the recurrence was detect-
ed. Thus, radiation may be an option if it has not been
used before, and surgeries such as rescue hysterectomy
may be the choice in cases previously treated with radio
and chemotherapy. Another alternative rarely used is an-
terior, posterior or total pelvic exenteration. Most cases,
however, have been treated with chemotherapy. Several
prospective studies have shown that the schemes based
on the use of cisplatin
43
have no significant impact on
survival. The use of carboplatin leads to reduction of tox-
icity but has no better results in terms of survival.
A substantial gain in survival was observed in a pro-
spective phase 3 study (GOG 240). In this study, patients
received one of two chemotherapy regimens, with or with-
out bevacizumab as angiogenesis inhibitor (total of 4
arms). The drug is a monoclonal antibody directed to vas-
cular endothelial growth factor (VEGF). In the popula-
For patients with cancer at more advanced stages or
for those not eligible for conservative treatment, one op-
tion is ovarian transposition, with the purpose of main-
taining hormonal function and ovarian reserve. Surgery
consists of releasing the tube and ovary from the pelvic
infundibulum, attaching them above the edge of the pel-
vis, which is the cranial limit for pelvic radiotherapy fields.
It is suggested placing clips on the new topography of the
annexes, in order to identify these structures later on im-
aging studies. Keep in mind the risk of ovarian metasta-
sis from cervical carcinoma, which is 0.6% for squamous
cell carcinomas and 6% for adenocarcinomas, requiring
careful evaluation during surgery and removal of suspi-
cious attachments. The success rate is quite variable, and
often there is anticipation of menopause in cases treated
with transposition.
30
Some of this variation is due to concurrent or adju-
vant chemotherapy, which implies a high chance of ovar-
ian failure induced by the chemo in patients older than
35 years.
31-33
Other approaches to preserve fertility include
advanced procedures such as ovulation induction and
oocyte retrieval,
in vitro
fertilization and embryo freezing,
and preservation of ovarian tissue for reimplantation.
S
entinel
lymph
node
role
in
the
treatment
of
cervical
cancer
The rationale for the use of sentinel lymph node (SLN)
technique, such as in the case of breast carcinomas, is that
this is the first lymph node that receives drainage from the
tumor. Thus, if it is disease-free, the other nodes will also
be. And the patient is spared complete lymph node dissec-
tion, associated with high morbidity. The main study on
the use of this technique to treat cervical carcinomas is the
SENTICOL trial, which showed high sensitivity for detec-
tion of sentinel lymph node (92%), high negative predic-
tive value (98.2%), and no false-negative cases when there
was bilateral identification of sentinel lymph nodes.
34
Oth-
er studies have shown similar results.
35-37
However, the following criteria must be met: the tech-
nique is indicated for tumors in stages IA2, IB1 and IIA1
(tumor up to 4 cm), except for cases in which there is re-
duced sensibility using the method, such as in tumors
sized more than 2 cm; absence of lymph node involve-
ment (on imaging and intraoperative); bilateral identifi-
cation of the sentinel lymph node (at least one node in
each hemi-pelvis). The accuracy of the method is improved
by lymph nodal “ultra-staging” (serial sections of the sen-
tinel lymph node).
36,37
Nevertheless, it cannot be per-
formed during surgery, and, if the nodes are positive, a
second operation is needed. The SENTICOL II trial is cur-